Provider Demographics
NPI:1629271150
Name:POTTKOTTER, TIFFANY R (CNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:POTTKOTTER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1098
Practice Address - Country:US
Practice Address - Phone:419-294-4991
Practice Address - Fax:419-209-0278
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0500689101YM0800X
OHCOA16281NP101YP2500X
OHCOA16281-NP363L00000X
OHAPRN.CNP.16281363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0111791Medicaid
OHH441830Medicare PIN