Provider Demographics
NPI:1669904561
Name:POTTER, JENNIFER KNEEZEL
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KNEEZEL
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:KNEEZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 BLYTHE BLVD
Mailing Address - Street 2:CMC DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5812
Mailing Address - Country:US
Mailing Address - Phone:704-355-3181
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:CMC DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC227312207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine