Healthcare Provider Details

I. General information

NPI: 1346378296
Provider Name (Legal Business Name): ELLEN RAE PORTER HS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 UNION ST
CLARKSVILLE TN
37040-5115
US

IV. Provider business mailing address

342 GREENLEAF LN
CLARKSVILLE TN
37040-4367
US

V. Phone/Fax

Practice location:
  • Phone: 931-647-8257
  • Fax: 931-647-2987
Mailing address:
  • Phone: 931-206-2362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: