Provider Demographics
NPI:1740015106
Name:POTTER, DESIREE LW
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:LW
Last Name:POTTER
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 1:2006 LINDSEY LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-1930
Mailing Address - Country:US
Mailing Address - Phone:678-851-3854
Mailing Address - Fax:
Practice Address - Street 1:7127 ALLENTOWN RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-1526
Practice Address - Country:US
Practice Address - Phone:678-851-3854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO108685174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist