Provider Demographics
NPI:1700092640
Name:POTTER, GRACETTA RENEE (LAC)
Entity Type:Individual
Prefix:MS
First Name:GRACETTA
Middle Name:RENEE
Last Name:POTTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3144 E 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-4848
Mailing Address - Country:US
Mailing Address - Phone:509-534-5712
Mailing Address - Fax:509-534-5721
Practice Address - Street 1:3144 E 29TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4848
Practice Address - Country:US
Practice Address - Phone:509-534-5712
Practice Address - Fax:509-534-5721
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002265171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist