Healthcare Provider Details

I. General information

NPI: 1669023271
Provider Name (Legal Business Name): RONNIE ELIZABETH POTTS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RONNIE ELIZABETH LANGE

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23638 SKY HARBOR RD.
FRIANT CA
93626
US

IV. Provider business mailing address

11734 ROAD 33 1/2
MADERA CA
93636-8465
US

V. Phone/Fax

Practice location:
  • Phone: 559-316-6040
  • Fax:
Mailing address:
  • Phone: 209-606-2894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95012413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: