=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043425960
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS BOBBI JEAN PORTER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 903 MAGNOLIA ST
-----------------------------------------------------
City | COSHOCTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43812-2856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-622-0735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1536 TRADE AVE
-----------------------------------------------------
City | COSHOCTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43812-1453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-575-4019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------