Provider Demographics
NPI:1235945403
Name:PORTER, KEARRA (COSMETOLOGIST)
Entity type:Individual
Prefix:
First Name:KEARRA
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:COSMETOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2408 FOREST BROOK LN APT 2402
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-5309
Mailing Address - Country:US
Mailing Address - Phone:817-344-8855
Mailing Address - Fax:
Practice Address - Street 1:3415 S COOPER ST STE 106
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-3434
Practice Address - Country:US
Practice Address - Phone:817-344-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1679212335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier