Provider Demographics
NPI:1962430298
Name:PORTHOUSE, MARIE MICHELLE (NP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:MICHELLE
Last Name:PORTHOUSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 EMPIRE CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-1949
Mailing Address - Country:US
Mailing Address - Phone:540-891-1200
Mailing Address - Fax:540-891-1225
Practice Address - Street 1:4501 EMPIRE CT
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-1949
Practice Address - Country:US
Practice Address - Phone:540-891-1200
Practice Address - Fax:540-891-1225
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024079016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7788614Medicaid
VA7788614Medicaid
S27531Medicare UPIN