Provider Demographics
NPI:1518031269
Name:POTTER, HEATHER A (ARNP)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:POTTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:115 HUSTON DR
Practice Address - Street 2:SUITE 1
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-7250
Practice Address - Country:US
Practice Address - Phone:502-955-7311
Practice Address - Fax:502-955-9694
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003365363LF0000X
KY3365P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78005717Medicaid
KYK090220Medicare PIN
P21698Medicare UPIN
KY78005717Medicaid
KY78005717Medicare PIN