Provider Demographics
NPI:1568842607
Name:POTTER, KELLY (MED)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 BRENT ANN DR
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139-1422
Mailing Address - Country:US
Mailing Address - Phone:606-831-3606
Mailing Address - Fax:
Practice Address - Street 1:2215 BRENT ANN DR
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1422
Practice Address - Country:US
Practice Address - Phone:606-831-3606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200703699174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator