Healthcare Provider Details

I. General information

NPI: 1558378133
Provider Name (Legal Business Name): DELANA E POTTER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BRENTSHIRE SQ
JACKSON TN
38305-2245
US

IV. Provider business mailing address

1318 CAPOOTH RD
RAMER TN
38367-6163
US

V. Phone/Fax

Practice location:
  • Phone: 731-664-1717
  • Fax: 731-664-7114
Mailing address:
  • Phone: 731-693-4858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0000010789
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: