Provider Demographics
NPI:1245698794
Name:POTTER, MELISSA
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:WALKENHORST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:7509 CHARLESTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9623
Mailing Address - Country:US
Mailing Address - Phone:812-256-4686
Mailing Address - Fax:
Practice Address - Street 1:7509 CHARLESTOWN PIKE
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-9623
Practice Address - Country:US
Practice Address - Phone:812-256-4686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27067879A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse