Provider Demographics
NPI:1326326539
Name:POTOCKI, KAREN DIANE (ACNP)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:DIANE
Last Name:POTOCKI
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2910 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:480-917-5600
Mailing Address - Fax:602-294-4499
Practice Address - Street 1:1875 W FRYE RD STE 300
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6184
Practice Address - Country:US
Practice Address - Phone:480-917-5600
Practice Address - Fax:602-294-4497
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL#209003804163WN0800X
AZAP11368363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ402187Medicaid