Provider Demographics
NPI:1720211485
Name:POTTER, LAUREN DANIELLE (DPT)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:DANIELLE
Last Name:POTTER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1059
Mailing Address - Country:US
Mailing Address - Phone:607-257-5009
Mailing Address - Fax:607-257-9985
Practice Address - Street 1:2359 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1059
Practice Address - Country:US
Practice Address - Phone:607-257-5009
Practice Address - Fax:607-257-9985
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031774225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400052810Medicare UPIN