Provider Demographics
NPI:1952180499
Name:POTTER, STEPHANIE A
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
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 1:204 HARLEM RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-2911
Mailing Address - Country:US
Mailing Address - Phone:301-919-3040
Mailing Address - Fax:
Practice Address - Street 1:211 S VINCENT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-3040
Practice Address - Country:US
Practice Address - Phone:301-919-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker