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General NPI Number Information
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NPI Number | 1356489272
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Entity Type | Individual
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Provider Name | MARY ELLEN PORTER NP
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Gender | Female
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 09/11/2020
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Provider Practice Location Address
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Address Line | 1020 RIVER OAKS DR STE 100
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City | FLOWOOD
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State | MS
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Zip | 39232-9511
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Country | US
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Telephone | 601-326-8700
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Fax | 601-932-4681
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Provider Business Mailing Address
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Address Line | 1020 RIVER OAKS DR STE 100
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City | FLOWOOD
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State | MS
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Zip | 39232-9511
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Country | US
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Telephone | 601-326-8700
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Fax | 601-932-4681
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN098282
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP04559
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License Number State | LA
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