Provider Demographics
NPI:1083282370
Name:POTTER, MARTHA VIRGINIA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:VIRGINIA
Last Name:POTTER
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 1:35617 FERNWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-4107
Mailing Address - Country:US
Mailing Address - Phone:734-968-5360
Mailing Address - Fax:
Practice Address - Street 1:35617 FERNWOOD ST
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-4107
Practice Address - Country:US
Practice Address - Phone:734-968-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225766163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse