Provider Demographics
NPI:1700618899
Name:PORTER, MERCEDES S (RDN)
Entity type:Individual
Prefix:
First Name:MERCEDES
Middle Name:S
Last Name:PORTER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2649 N WAYNE AVE # 2FF
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-8289
Mailing Address - Country:US
Mailing Address - Phone:913-713-2889
Mailing Address - Fax:
Practice Address - Street 1:2649 N WAYNE AVE # 2FF
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-8289
Practice Address - Country:US
Practice Address - Phone:913-713-2889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO86391206133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered