Provider Demographics
NPI:1528889599
Name:PORTER, EVELYN LORENE
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:LORENE
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 1:32377 US HIGHWAY 60
Mailing Address - Street 2:
Mailing Address - City:ELLSINORE
Mailing Address - State:MO
Mailing Address - Zip Code:63937-8693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32377 US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:ELLSINORE
Practice Address - State:MO
Practice Address - Zip Code:63937-8693
Practice Address - Country:US
Practice Address - Phone:573-323-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator