Provider Demographics
NPI:1356747513
Name:POTTS, KRISTINA
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:POTTS
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 1:774 GRAVOIS BLUFFS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-7758
Mailing Address - Country:US
Mailing Address - Phone:636-685-7734
Mailing Address - Fax:314-590-5922
Practice Address - Street 1:774 GRAVOIS BLUFFS BLVD STE B
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026
Practice Address - Country:US
Practice Address - Phone:636-685-7734
Practice Address - Fax:314-590-5922
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF1014589363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily