Healthcare Provider Details

I. General information

NPI: 1336790146
Provider Name (Legal Business Name): MADELYNE KAYE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1893 E SKYLINE DR STE 204
SOUTH OGDEN UT
84403-5228
US

IV. Provider business mailing address

4339 S 2350 W
ROY UT
84067-2013
US

V. Phone/Fax

Practice location:
  • Phone: 801-621-1667
  • Fax:
Mailing address:
  • Phone: 757-771-6783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9505343-4701
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number148704
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: