Healthcare Provider Details

I. General information

NPI: 1477712396
Provider Name (Legal Business Name): CLOIE DENITA PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 APPLEGATE RD
LUCAS OH
44843-9718
US

IV. Provider business mailing address

2640 APPLEGATE RD
LUCAS OH
44843-9718
US

V. Phone/Fax

Practice location:
  • Phone: 419-892-2895
  • Fax:
Mailing address:
  • Phone: 419-892-2895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN.111913
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN. 111913
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: