Provider Demographics
NPI:1588712079
Name:PORTER, MELANIE (NP)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2353 SE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50320-1109
Mailing Address - Country:US
Mailing Address - Phone:515-248-1400
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:979 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2102
Practice Address - Country:US
Practice Address - Phone:515-248-1500
Practice Address - Fax:515-248-1510
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-052232363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAS86304Medicare UPIN