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General NPI Number Information
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NPI Number | 1790931400
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Entity Type | Individual
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Provider Name | MANDI LASHEA PORTER PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 08/13/2008
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Last Update Date | 04/15/2021
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Provider Practice Location Address
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Address Line | 2520 5TH ST N
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City | COLUMBUS
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State | MS
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Zip | 39705-2008
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Country | US
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Telephone | 662-244-2074
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Fax |
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Provider Business Mailing Address
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Address Line | 4092 MERRILLVILLE DR. APT 14105
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City | WEST MELBOURNE
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State | FL
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Zip | 32904
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Country | US
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Telephone | 707-514-5037
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 00010707
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5038
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 34857
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License Number State | CA
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