Healthcare Provider Details

I. General information

NPI: 1275177438
Provider Name (Legal Business Name): ANNIE RACHEL POOLE POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNIE POOLE

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 CAROLINA BEACH RD
WILMINGTON NC
28412-2908
US

IV. Provider business mailing address

315 WIMBLEDON CT
WILMINGTON NC
28412-7374
US

V. Phone/Fax

Practice location:
  • Phone: 910-254-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number0119008388
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: