Provider Demographics
NPI:1306242177
Name:PORTER, TAMALA
Entity type:Individual
Prefix:
First Name:TAMALA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SAN RAFAEL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-2413
Mailing Address - Country:US
Mailing Address - Phone:419-297-6059
Mailing Address - Fax:
Practice Address - Street 1:75 SAN RAFAEL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43607-2413
Practice Address - Country:US
Practice Address - Phone:419-297-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0109405OtherMEDICAID INDEPENDENT PROVIDER NUMBER