Provider Demographics
NPI:1487412615
Name:PORTIS, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PORTIS
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 1:10515 W MARKHAM ST STE L7
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-2288
Mailing Address - Country:US
Mailing Address - Phone:501-393-0083
Mailing Address - Fax:501-391-7272
Practice Address - Street 1:10515 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-2297
Practice Address - Country:US
Practice Address - Phone:501-393-0083
Practice Address - Fax:501-391-7272
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARBL1660013104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances