MEDICARE: TILLIE 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1386432318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TILLIE PORTER

Provider Business Mailing Address
First Line	:	4932 CALIFORNIA ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68132-2418
Country	:	US
Telephone Number	:	217-319-8509
Fax Number	:

Provider Business Practice Location Address
First Line	:	4932 CALIFORNIA ST
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68132-2418
Country	:	US
Telephone Number	:	217-319-8509
Fax Number	:

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

Provider Enumeration Date	:	04/29/2025
Last Update Date	:	04/29/2025

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Directions to “ TILLIE PORTER ” Practice Location

Language	Start Address	Practice Location

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