Provider Demographics
NPI:1831301407
Name:POTTER, MARIMIKEL (RN-BSN, LM, CPM)
Entity Type:Individual
Prefix:MS
First Name:MARIMIKEL
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:RN-BSN, LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9302 CASTLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6010
Mailing Address - Country:US
Mailing Address - Phone:512-477-5452
Mailing Address - Fax:512-477-5616
Practice Address - Street 1:9302 CASTLEWOOD DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6010
Practice Address - Country:US
Practice Address - Phone:512-477-5452
Practice Address - Fax:512-477-5616
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX96080176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742112060OtherTAX IDENTIFICATION NUMBER