Healthcare Provider Details

I. General information

NPI: 1285404830
Provider Name (Legal Business Name): HAILEY PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 01/04/2024
Certification Date: 01/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61850 DOBBIN RD
BEND OR
97702-9536
US

IV. Provider business mailing address

3139 SW TIMBER CT
REDMOND OR
97756-7508
US

V. Phone/Fax

Practice location:
  • Phone: 541-241-3109
  • Fax:
Mailing address:
  • Phone: 520-255-9186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: