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General NPI Number Information
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NPI Number | 1073167573
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Entity Type | Individual
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Provider Name | DANITA RENAE POTTER PMHNP
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Gender | Female
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Dates
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Enumeration Date | 08/01/2019
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Last Update Date | 07/15/2020
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Provider Practice Location Address
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Address Line | 518 DURHAM ST
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City | BASTROP
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State | LA
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Zip | 71220-5013
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Country | US
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Telephone | 318-283-8887
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Fax | 318-281-2559
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Provider Business Mailing Address
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Address Line | PO BOX 792
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City | BASTROP
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State | LA
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Zip | 71221-0792
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Country | US
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Telephone | 318-283-8887
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Fax | 318-281-2559
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 206980
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License Number State | LA
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