Healthcare Provider Details

I. General information

NPI: 1124372412
Provider Name (Legal Business Name): KELLY ANN POTTS DOM AP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 EVELYN AVENUE
CLEARWATER FL
33765
US

IV. Provider business mailing address

112 EVELYN AVENUE
CLEARWATER FL
33765
US

V. Phone/Fax

Practice location:
  • Phone: 813-765-2493
  • Fax:
Mailing address:
  • Phone: 813-765-2493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 3176
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: