Healthcare Provider Details

I. General information

NPI: 1396171468
Provider Name (Legal Business Name): KELLI LYNN POTTER CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 09/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W CRYSTAL LAKE ST SUITE 300
ORLANDO FL
32806-4435
US

IV. Provider business mailing address

8736 RANCHO CT
ORLANDO FL
32836-5831
US

V. Phone/Fax

Practice location:
  • Phone: 407-254-2549
  • Fax: 407-849-6882
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number120940
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: