Provider Demographics
NPI:1427107895
Name:PORCH, MARY CATHERINE (APRN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:PORCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1375 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3147
Mailing Address - Country:US
Mailing Address - Phone:985-649-1152
Mailing Address - Fax:985-643-9808
Practice Address - Street 1:56 STARBRUSH CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7208
Practice Address - Country:US
Practice Address - Phone:985-871-0095
Practice Address - Fax:985-871-0529
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX738795363LF0000X
LAAP03785363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500001746Medicare ID - Type Unspecified