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General NPI Number Information
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NPI Number | 1114471885
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Entity Type | Individual
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Provider Name | MILDRED MARIE PORTER
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Gender | Female
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Dates
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Enumeration Date | 08/10/2016
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Last Update Date | 08/10/2016
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Provider Practice Location Address
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Address Line | 2259 S WESTERN AVE APT 2
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City | CHICAGO
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State | IL
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Zip | 60608-4476
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Country | US
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Telephone | 312-738-3355
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Fax |
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Provider Business Mailing Address
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Address Line | 14442 ABBOTTSFORD RD
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City | MIDLOTHIAN
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State | IL
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Zip | 60445-2902
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Country | US
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Telephone | 708-371-7817
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 209013926
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License Number State | IL
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