Healthcare Provider Details

I. General information

NPI: 1902585755
Provider Name (Legal Business Name): DANIELLE PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 HARVEY ST
CHEYENNE WY
82009-4595
US

IV. Provider business mailing address

3600 HARVEY ST
CHEYENNE WY
82009-4595
US

V. Phone/Fax

Practice location:
  • Phone: 307-262-4460
  • Fax:
Mailing address:
  • Phone: 307-262-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberDEEA2A6F9D
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-315138
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: