Provider Demographics
NPI:1942878368
Name:POTTER, KIMBERLY LYNNE (NURSE)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNNE
Last Name:POTTER
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 MILL ST
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-2786
Mailing Address - Country:US
Mailing Address - Phone:920-266-5581
Mailing Address - Fax:920-533-6009
Practice Address - Street 1:235 MILL ST
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-2786
Practice Address - Country:US
Practice Address - Phone:920-266-5581
Practice Address - Fax:920-533-6009
Is Sole Proprietor?:No
Enumeration Date:2021-06-13
Last Update Date:2021-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI304735-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse