Healthcare Provider Details

I. General information

NPI: 1114636776
Provider Name (Legal Business Name): JANESA PORTER DNP, CPNP AC/PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 01/23/2026
Certification Date: 01/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1103
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-487-0451
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9796639-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP026647
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: