Provider Demographics
NPI:1215924592
Name:PORTER, SUSANNE L (NP)
Entity type:Individual
Prefix:
First Name:SUSANNE
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSANNE
Other - Middle Name:L
Other - Last Name:SNELLGROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-6905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 S MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3852
Practice Address - Country:US
Practice Address - Phone:714-634-4567
Practice Address - Fax:714-634-4569
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14777363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNP14777AMedicare PIN