Provider Demographics
NPI:1639515810
Name:POTTER, ANGELA J (ATC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:POTTER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 COLLEGE AVE
Mailing Address - Street 2:COSTELLO SPORTS COMPLEX
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1032
Mailing Address - Country:US
Mailing Address - Phone:207-780-5943
Mailing Address - Fax:207-780-5354
Practice Address - Street 1:37 COLLEGE AVE
Practice Address - Street 2:COSTELLO SPORTS COMPLEX
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1032
Practice Address - Country:US
Practice Address - Phone:207-780-5943
Practice Address - Fax:207-780-5354
Is Sole Proprietor?:No
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAT2212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer