Healthcare Provider Details

I. General information

NPI: 1093535866
Provider Name (Legal Business Name): KAYLEE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 VIRGINIA AVE
INDIANAPOLIS IN
46203-1712
US

IV. Provider business mailing address

9346 S COUNTY ROAD 765 W
REELSVILLE IN
46171-8860
US

V. Phone/Fax

Practice location:
  • Phone: 317-384-3491
  • Fax: 407-650-2754
Mailing address:
  • Phone: 317-384-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: