Provider Demographics
NPI:1073167573
Name:POTTER, DANITA RENAE (PMHNP)
Entity Type:Individual
Prefix:DR
First Name:DANITA
Middle Name:RENAE
Last Name:POTTER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-0792
Mailing Address - Country:US
Mailing Address - Phone:318-283-8887
Mailing Address - Fax:318-281-2559
Practice Address - Street 1:518 DURHAM ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5013
Practice Address - Country:US
Practice Address - Phone:318-283-8887
Practice Address - Fax:318-281-2559
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA206980363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health