Provider Demographics
NPI:1437513108
Name:POTTER MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:POTTER MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER FNP
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-820-3999
Mailing Address - Street 1:205 N DEER CREEK DR E
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-2749
Mailing Address - Country:US
Mailing Address - Phone:662-820-3999
Mailing Address - Fax:662-702-5121
Practice Address - Street 1:1462 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7140
Practice Address - Country:US
Practice Address - Phone:662-702-5121
Practice Address - Fax:662-702-5123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857846363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08175511Medicaid
MS08175511Medicaid