Healthcare Provider Details

I. General information

NPI: 1053042689
Provider Name (Legal Business Name): JENNIFER POTTER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WAYNE MEMORIAL DR
GOLDSBORO NC
27534-9494
US

IV. Provider business mailing address

214 BLAND HOWELL RD
KINSTON NC
28504-7499
US

V. Phone/Fax

Practice location:
  • Phone: 919-736-1110
  • Fax:
Mailing address:
  • Phone: 252-560-1991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5016417
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: