Provider Demographics
NPI:1902617996
Name:PORTER, MICKI
Entity type:Individual
Prefix:
First Name:MICKI
Middle Name:
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 1:4513 COUNTY ROAD 12
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-8304
Mailing Address - Country:US
Mailing Address - Phone:740-222-9103
Mailing Address - Fax:
Practice Address - Street 1:4513 COUNTY ROAD 12
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8304
Practice Address - Country:US
Practice Address - Phone:740-222-9103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker