Provider Demographics
NPI:1609333509
Name:PORTER, ESTACY (DNP, FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ESTACY
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:DNP, FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6231 FREEDOM CIR STE 2
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-1213
Mailing Address - Country:US
Mailing Address - Phone:757-788-9578
Mailing Address - Fax:
Practice Address - Street 1:5121 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-6448
Practice Address - Country:US
Practice Address - Phone:706-426-1642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78383-111363LC1500X
GARN200693363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily