Healthcare Provider Details

I. General information

NPI: 1306775275
Provider Name (Legal Business Name): GINGER DEROCHE PORTER PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 WIGGINS ESTATES LN
HOLLY HILL SC
29059-9346
US

IV. Provider business mailing address

439 WIGGINS ESTATES LN
HOLLY HILL SC
29059-9346
US

V. Phone/Fax

Practice location:
  • Phone: 719-214-0662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number31966
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: