Provider Demographics
NPI:1003640335
Name:POTTER, LAN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LAN
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 57TH CIR E APT 202
Mailing Address - Street 2:2640 57TH CIR E APT 202
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222
Mailing Address - Country:US
Mailing Address - Phone:319-671-2270
Mailing Address - Fax:
Practice Address - Street 1:2640 57TH CIR E APT 202
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222
Practice Address - Country:US
Practice Address - Phone:319-671-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11032275363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care