Provider Demographics
NPI:1962388488
Name:PORTER, MIKELLE (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:MIKELLE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 BROADDRICK LN
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-8951
Mailing Address - Country:US
Mailing Address - Phone:479-208-8689
Mailing Address - Fax:
Practice Address - Street 1:8411 S 28TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8646
Practice Address - Country:US
Practice Address - Phone:479-648-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR203261390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program