Provider Demographics
NPI:1700378015
Name:POTTER, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 APACHE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7404
Mailing Address - Country:US
Mailing Address - Phone:870-215-3108
Mailing Address - Fax:
Practice Address - Street 1:3100 APACHE DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7404
Practice Address - Country:US
Practice Address - Phone:870-333-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1164957080222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist