Provider Demographics
NPI:1124254511
Name:POTT, AILEEN MARIE
Entity type:Individual
Prefix:
First Name:AILEEN
Middle Name:MARIE
Last Name:POTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:MARIE
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9137 MORITZ AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1625
Mailing Address - Country:US
Mailing Address - Phone:305-298-2692
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-577-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-31
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant