Provider Demographics
NPI:1154621423
Name:RICHARDSON, PORSHA LYNN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:PORSHA
Middle Name:LYNN
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10832
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140-1832
Mailing Address - Country:US
Mailing Address - Phone:405-208-4573
Mailing Address - Fax:405-429-4083
Practice Address - Street 1:1117 S DOUGLAS BLVD STE B
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5265
Practice Address - Country:US
Practice Address - Phone:405-208-4573
Practice Address - Fax:405-429-4083
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-02
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN182800363LA2200X
NY306010363LA2200X
CA20472363LA2200X
NY421072363LW0102X
OK83097363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK83097OtherLICENSE
OK200532830AMedicaid