Healthcare Provider Details

I. General information

NPI: 1811715063
Provider Name (Legal Business Name): KAYLA PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 WILDCAT WAY
LOGAN WV
25601-3474
US

IV. Provider business mailing address

506 HOLLY AVE
LOGAN WV
25601-3306
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-1804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number109682
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: