Provider Demographics
NPI:1184859415
Name:POTTS, ELLEN LOUISE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:LOUISE
Last Name:POTTS
Suffix:
Gender:F
Credentials:ARNP
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 57967
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-7967
Mailing Address - Country:US
Mailing Address - Phone:904-886-4878
Mailing Address - Fax:904-884-7438
Practice Address - Street 1:2140 KINGSLEY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-886-4878
Practice Address - Fax:904-886-7438
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP668652363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300892400Medicaid
FLE4523ZMedicare PIN