MEDICARE: SUNNY POTTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1356092068
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNNY POTTER

Provider Business Mailing Address
First Line	:	410 S RAMPART BLVD STE 390
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89145-5749
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	714 BRACKEN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1644
Country	:	US
Telephone Number	:	907-612-1085
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	01/13/2022

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Directions to “ SUNNY POTTER ” Practice Location

Language	Start Address	Practice Location

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