Provider Demographics
NPI:1851912141
Name:POTTER, RACHAEL MARIE (RN)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:MARIE
Last Name:POTTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 STEELHAMMER DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-4551
Mailing Address - Country:US
Mailing Address - Phone:360-623-8020
Mailing Address - Fax:360-623-1072
Practice Address - Street 1:500 SE WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3058
Practice Address - Country:US
Practice Address - Phone:360-748-4776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60623475163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2077844Medicaid