Provider Demographics
NPI:1518721109
Name:POTTS, GUNNER
Entity Type:Individual
Prefix:
First Name:GUNNER
Middle Name:
Last Name:POTTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:AL
Mailing Address - Zip Code:35043-6906
Mailing Address - Country:US
Mailing Address - Phone:205-259-9330
Mailing Address - Fax:
Practice Address - Street 1:1707 NW SAINT LUCIE WEST BLVD STE 188
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2521
Practice Address - Country:US
Practice Address - Phone:772-878-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41368225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist