Healthcare Provider Details

I. General information

NPI: 1306775549
Provider Name (Legal Business Name): KYRA POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 12TH ST
OAKLAND CA
94607-4927
US

IV. Provider business mailing address

9065 ANCESTOR DR
ELK GROVE CA
95758-1224
US

V. Phone/Fax

Practice location:
  • Phone: 800-607-6377
  • Fax:
Mailing address:
  • Phone: 916-384-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: