Provider Demographics
NPI:1013633403
Name:POTTER, CASSANDRA NICOLE
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:NICOLE
Last Name:POTTER
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 1:5820 HERRITAGE LANDING DR.
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13507
Mailing Address - Country:US
Mailing Address - Phone:315-701-1107
Mailing Address - Fax:
Practice Address - Street 1:5820 HERRITAGE LANDING DR.
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13507
Practice Address - Country:US
Practice Address - Phone:315-701-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist