Provider Demographics
NPI:1376432153
Name:MABASA, PORTIA
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:MABASA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 FALLEN APPLE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4776
Mailing Address - Country:US
Mailing Address - Phone:502-876-7360
Mailing Address - Fax:
Practice Address - Street 1:4519 FALLEN APPLE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4776
Practice Address - Country:US
Practice Address - Phone:502-876-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant