Healthcare Provider Details

I. General information

NPI: 1902245525
Provider Name (Legal Business Name): AMY M PORTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S UNIVERSITY AVE
PROVO UT
84601-4427
US

IV. Provider business mailing address

151 S UNIVERSITY AVE SUITE 1900
PROVO UT
84601-4427
US

V. Phone/Fax

Practice location:
  • Phone: 801-851-7024
  • Fax: 801-851-7063
Mailing address:
  • Phone: 801-851-7042
  • Fax: 801-851-7063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number2677378-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: