Provider Demographics
NPI:1760662852
Name:YOUTHFUL ESSENCE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:YOUTHFUL ESSENCE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:606-743-1600
Mailing Address - Street 1:842 HUTCHINSON RD
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-2032
Mailing Address - Country:US
Mailing Address - Phone:606-743-1600
Mailing Address - Fax:606-743-2220
Practice Address - Street 1:1412 KY-7
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472
Practice Address - Country:US
Practice Address - Phone:606-743-1600
Practice Address - Fax:606-743-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3285P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78004843Medicaid
9286Medicare PIN
KY78004843Medicaid
9287Medicare PIN