Healthcare Provider Details

I. General information

NPI: 1356489272
Provider Name (Legal Business Name): MARY ELLEN PORTER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 RIVER OAKS DR STE 100
FLOWOOD MS
39232-9511
US

IV. Provider business mailing address

1020 RIVER OAKS DR STE 100
FLOWOOD MS
39232-9511
US

V. Phone/Fax

Practice location:
  • Phone: 601-326-8700
  • Fax: 601-932-4681
Mailing address:
  • Phone: 601-326-8700
  • Fax: 601-932-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN098282
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP04559
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: