Provider Demographics
NPI:1346897022
Name:POTTER, D'OVIONNE NYDASIA
Entity Type:Individual
Prefix:
First Name:D'OVIONNE
Middle Name:NYDASIA
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 1:2122 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4430
Mailing Address - Country:US
Mailing Address - Phone:931-490-1480
Mailing Address - Fax:
Practice Address - Street 1:202 CHAPMAN LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2622
Practice Address - Country:US
Practice Address - Phone:931-698-8359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320700000X
TN320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities