Provider Demographics
NPI:1467557652
Name:POTVIN, SUZANNE H (ARNP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:H
Last Name:POTVIN
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 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:2400 EASTPOINT PKWY
Practice Address - Street 2:SUITE 550
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4154
Practice Address - Country:US
Practice Address - Phone:502-253-6630
Practice Address - Fax:502-253-6639
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2123P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1064753OtherRN LICENSE
KY7100007420Medicaid
KY7100007420Medicaid