Provider Demographics
NPI:1407545908
Name:PORTER, KATHRYN (CPNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7276 SOUTHCREST PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-4760
Mailing Address - Country:US
Mailing Address - Phone:662-349-6577
Mailing Address - Fax:662-349-6562
Practice Address - Street 1:7276 SOUTHCREST PKWY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4760
Practice Address - Country:US
Practice Address - Phone:626-349-6577
Practice Address - Fax:662-349-6562
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS905937208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics