Provider Demographics
NPI:1942417027
Name:POTZERNITZ, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:POTZERNITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2284
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-2284
Mailing Address - Country:US
Mailing Address - Phone:307-733-4119
Mailing Address - Fax:307-733-4119
Practice Address - Street 1:3066 RANGEVIEW # 3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-2284
Practice Address - Country:US
Practice Address - Phone:307-733-4119
Practice Address - Fax:307-733-4119
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator