MEDICARE: LALISIA PORTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	27450	TN

General Provider Information

NPI Number	:	1326663477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LALISIA PORTER

Provider Business Mailing Address
First Line	:	6524 KESWICK CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38119-7608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6222 E SHELBY DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38141-7735
Country	:	US
Telephone Number	:	901-878-3274
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2020
Last Update Date	:	06/15/2020

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Directions to “ LALISIA PORTER ” Practice Location

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