Healthcare Provider Details

I. General information

NPI: 1336574714
Provider Name (Legal Business Name): COLLEEN JEAN POTTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5667 PEACHTREE DUNWOODY RD 330
ATLANTA GA
30342-1725
US

IV. Provider business mailing address

5667 PEACHTREE DUNWOODY RD 330
ATLANTA GA
30342-1725
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-5669
  • Fax:
Mailing address:
  • Phone: 404-252-5669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN056458
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: