Provider Demographics
NPI:1699800698
Name:PORTER, VICKI MARIE (L P T)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:L P T
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2632
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-2632
Mailing Address - Country:US
Mailing Address - Phone:760-379-3412
Mailing Address - Fax:760-379-1364
Practice Address - Street 1:2731 NUGGET AVE.
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-2632
Practice Address - Country:US
Practice Address - Phone:760-379-3412
Practice Address - Fax:760-379-1364
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 30178167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician