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General NPI Number Information
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NPI Number | 1578800397
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Entity Type | Individual
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Provider Name | KAILEIGH M PORTER RD CDE
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Gender | Female
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Dates
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Enumeration Date | 01/14/2013
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Last Update Date | 07/06/2018
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Provider Practice Location Address
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Address Line | 900 BROADWAY BLDG 3
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-907-1187
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Fax | 207-907-1189
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Provider Business Mailing Address
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Address Line | 905 UNION ST STE 11
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City | BANGOR
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State | ME
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Zip | 04401-3039
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Country | US
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Telephone | 207-973-7334
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Fax | 207-973-7424
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | DI1186
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | TD1145
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License Number State | ME
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