Healthcare Provider Details

I. General information

NPI: 1083918197
Provider Name (Legal Business Name): MICHELLE M. PORTER RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S 9TH ST 6TH FLOOR WALNUT TOWERS
PHILADELPHIA PA
19107-6810
US

IV. Provider business mailing address

211 S 9TH ST SUITE 600
PHILADELPHIA PA
19107-6810
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-1925
  • Fax: 215-928-3160
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDN004010
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: