Provider Demographics
NPI:1841817798
Name:POTTER, ALLEN (FNP)
Entity type:Individual
Prefix:MR
First Name:ALLEN
Middle Name:
Last Name:POTTER
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 WELLINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4321
Mailing Address - Country:US
Mailing Address - Phone:321-350-2045
Mailing Address - Fax:
Practice Address - Street 1:1 SOMDG
Practice Address - Street 2:113 LIELMANIS AVE
Practice Address - City:HURLBURT AFB
Practice Address - State:FL
Practice Address - Zip Code:32544
Practice Address - Country:US
Practice Address - Phone:850-881-2569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001842363LF0000X
FL11001842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1841817798Medicaid