Provider Demographics
NPI:1487233565
Name:PORTER, ANNA THERESE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:THERESE
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 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-470-1936
Mailing Address - Fax:
Practice Address - Street 1:W3985 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4337
Practice Address - Country:US
Practice Address - Phone:262-741-2316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2020169171363LF0000X
WI11214-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily