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General NPI Number Information
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NPI Number | 1750974036
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Entity Type | Individual
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Provider Name | KYRIE POTTER LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 02/17/2021
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Last Update Date | 02/17/2021
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Provider Practice Location Address
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Address Line | 3001 S CREASY LN STE B
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City | LAFAYETTE
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State | IN
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Zip | 47905-5206
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Country | US
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Telephone | 765-423-6885
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Fax |
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Provider Business Mailing Address
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Address Line | 3163 PHEASANT RUN DR APT 524
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City | LAFAYETTE
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State | IN
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Zip | 47909-3363
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Country | US
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Telephone | 812-528-4432
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Fax |
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 36003354A
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License Number State | IN
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