Provider Demographics
NPI:1154508307
Name:POTHORSKI, AMY DENISE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DENISE
Last Name:POTHORSKI
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 1:133 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-1263
Mailing Address - Country:US
Mailing Address - Phone:740-694-1145
Mailing Address - Fax:
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-1263
Practice Address - Country:US
Practice Address - Phone:740-694-1145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 128710164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2794632Medicaid