Provider Demographics
NPI:1427161074
Name:PORTER, WADEANA NICOLE (MED, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:WADEANA
Middle Name:NICOLE
Last Name:PORTER
Suffix:
Gender:F
Credentials:MED, CCC-SLP
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 31033
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27622-1033
Mailing Address - Country:US
Mailing Address - Phone:919-389-4770
Mailing Address - Fax:919-327-4576
Practice Address - Street 1:5301 CORINTHIAN WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3611
Practice Address - Country:US
Practice Address - Phone:919-389-4770
Practice Address - Fax:919-327-4576
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC142UVOtherBCBS OF NC
NC7412281Medicaid