Healthcare Provider Details

I. General information

NPI: 1588870489
Provider Name (Legal Business Name): SUSANNE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 HWY 2417
CORBIN KY
40701
US

IV. Provider business mailing address

131 KEENELAND TRL
CORBIN KY
40701-8544
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-5732
  • Fax: 606-523-5727
Mailing address:
  • Phone: 606-523-5732
  • Fax: 606-523-5727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: