Healthcare Provider Details

I. General information

NPI: 1134028087
Provider Name (Legal Business Name): MISS WILMER YVETTE POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2026
Last Update Date: 11/05/2026
Certification Date: 11/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 NAGLEE RD STE 190
TRACY CA
95304-7329
US

IV. Provider business mailing address

667 W CORAZON WAY
MOUNTAIN HOUSE CA
95391-2049
US

V. Phone/Fax

Practice location:
  • Phone: 925-477-6945
  • Fax:
Mailing address:
  • Phone: 925-477-6945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number06024069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: