Healthcare Provider Details

I. General information

NPI: 1164041562
Provider Name (Legal Business Name): MCKENNA RAY CAMPBELL-POTTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E 70TH ST
NEW YORK NY
10021-4823
US

IV. Provider business mailing address

535 E 70TH ST
NEW YORK NY
10021-4823
US

V. Phone/Fax

Practice location:
  • Phone: 212-606-1791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number328701
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: