Healthcare Provider Details

I. General information

NPI: 1588370563
Provider Name (Legal Business Name): KIMBERLY PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 EASTMAN RD STE B
CENTER CONWAY NH
03813-4219
US

IV. Provider business mailing address

626 EASTMAN RD STE A
CENTER CONWAY NH
03813-4219
US

V. Phone/Fax

Practice location:
  • Phone: 603-447-2111
  • Fax: 603-447-1021
Mailing address:
  • Phone: 603-447-3347
  • Fax: 603-447-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number043805-23
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number043805-21
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: