Healthcare Provider Details

I. General information

NPI: 1497056428
Provider Name (Legal Business Name): CASSANDRA E PORTER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4634 HILLS AND DALES RD NW
CANTON OH
44708-1510
US

IV. Provider business mailing address

4634 HILLS AND DALES RD NW
CANTON OH
44708-1510
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-1480
  • Fax: 330-493-6805
Mailing address:
  • Phone: 330-477-0255
  • Fax: 330-479-0392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP11954
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: