Provider Demographics
NPI:1174928691
Name:DEBREW, PORTIA RAMONA (LPN)
Entity type:Individual
Prefix:MS
First Name:PORTIA
Middle Name:RAMONA
Last Name:DEBREW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 BRAMBLE WAY
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-5445
Mailing Address - Country:US
Mailing Address - Phone:678-670-6209
Mailing Address - Fax:
Practice Address - Street 1:125 BRAMBLE WAY
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-5445
Practice Address - Country:US
Practice Address - Phone:678-670-6209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN083753164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPN083753OtherLICENSE PRACTICAL NURSE