MEDICARE: VALERIE LOUISE POTTER LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	25435	WV
2	164W00000X	Licensed Practical Nurse	0002088630	VA

General Provider Information

NPI Number	:	1104215565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VALERIE LOUISE POTTER LPN

Provider Business Mailing Address
First Line	:	4928 FORD HILL ROAD
Second Line	:
City	:	AUGUSTA
State	:	WV
Zip	:	26704
Country	:	US
Telephone Number	:	304-851-4459
Fax Number	:

Provider Business Practice Location Address
First Line	:	4928 FORD HILL ROAD
Second Line	:
City	:	AUGUSTA
State	:	WV
Zip	:	26704
Country	:	US
Telephone Number	:	304-851-4459
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2015
Last Update Date	:	01/22/2015

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