Provider Demographics
NPI:1982981718
Name:POTTS-WILSON, CHRISTINE
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:
Last Name:POTTS-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:POTTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:4818 MORAGA LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6382
Mailing Address - Country:US
Mailing Address - Phone:775-848-7893
Mailing Address - Fax:
Practice Address - Street 1:4818 MORAGA LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-6382
Practice Address - Country:US
Practice Address - Phone:775-848-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA37149163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)