Healthcare Provider Details

I. General information

NPI: 1992763577
Provider Name (Legal Business Name): ANGELA MARIE POTTS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA MARIE TIARKS

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3248 VANDEVER AVE
PEKIN IL
61554
US

IV. Provider business mailing address

3248 VANDEVER AVE
PEKIN IL
61554
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-5522
  • Fax: 309-347-4264
Mailing address:
  • Phone: 309-347-5522
  • Fax: 309-347-4264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: