Provider Demographics
NPI:1699986661
Name:PORTER, GWEN LEE (RN)
Entity type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:LEE
Last Name:PORTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 W 39TH ST
Mailing Address - Street 2:
Mailing Address - City:SHADYSIDE
Mailing Address - State:OH
Mailing Address - Zip Code:43947-1106
Mailing Address - Country:US
Mailing Address - Phone:740-676-1710
Mailing Address - Fax:740-676-7200
Practice Address - Street 1:24 W 39TH ST
Practice Address - Street 2:
Practice Address - City:SHADYSIDE
Practice Address - State:OH
Practice Address - Zip Code:43947-1106
Practice Address - Country:US
Practice Address - Phone:740-676-1710
Practice Address - Fax:740-676-7200
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20872163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management