Healthcare Provider Details

I. General information

NPI: 1356747513
Provider Name (Legal Business Name): KRISTINA POTTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

774 GRAVOIS BLUFFS BLVD STE B
FENTON MO
63026
US

IV. Provider business mailing address

774 GRAVOIS BLUFFS BLVD STE B
FENTON MO
63026-7758
US

V. Phone/Fax

Practice location:
  • Phone: 636-685-7734
  • Fax: 314-590-5922
Mailing address:
  • Phone: 636-685-7734
  • Fax: 314-590-5922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF1014589
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: