Provider Demographics
NPI:1356747158
Name:POTTER, WAYNE (LPN)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:WR
Other - Middle Name:
Other - Last Name:POTTER HOMECARE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1426 COUNTY ROAD 8
Mailing Address - Street 2:
Mailing Address - City:SHORTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14548-9748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1426 COUNTY ROAD 8
Practice Address - Street 2:
Practice Address - City:SHORTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14548-9748
Practice Address - Country:US
Practice Address - Phone:585-746-9466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY283617164W00000X
372600000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide