Provider Demographics
NPI:1245035666
Name:POTTER, CAITLIN RAE
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:RAE
Last Name:POTTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11232 W HAZELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-6387
Mailing Address - Country:US
Mailing Address - Phone:208-571-1409
Mailing Address - Fax:
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic