Provider Demographics
NPI:1124372412
Name:POTTS, KELLY ANN (DOM AP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:POTTS
Suffix:
Gender:F
Credentials:DOM AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 EVELYN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765
Mailing Address - Country:US
Mailing Address - Phone:813-765-2493
Mailing Address - Fax:
Practice Address - Street 1:112 EVELYN AVENUE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765
Practice Address - Country:US
Practice Address - Phone:813-765-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 3176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist