Provider Demographics
NPI:1437357043
Name:POTTORFF, TINA MARIE (CPNP, CDE)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:POTTORFF
Suffix:
Gender:F
Credentials:CPNP, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-777-6435
Mailing Address - Fax:317-777-6644
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:RI 5960
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-3889
Practice Address - Fax:317-944-3882
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28109103A363LP0200X
IN71002350A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201108710Medicaid
IN145590113Medicare PIN