Basic Information
| Provider Information | |||||||||
| NPI: | 1366053217 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207592694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013408339 | ||||||||
| FaxNumber: | 3013409027 | ||||||||
| Practice Location | |||||||||
| Address1: | 3060 MITCHELLVILLE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | BOWIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207163969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102451563 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | R178637 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LX0001X | R178637 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
No ID Information.