Provider Demographics
NPI:1093535866
Name:POTTER, KAYLEE
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9346 S COUNTY ROAD 765 W
Mailing Address - Street 2:
Mailing Address - City:REELSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46171-8860
Mailing Address - Country:US
Mailing Address - Phone:317-384-3491
Mailing Address - Fax:
Practice Address - Street 1:1201 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-1784
Practice Address - Country:US
Practice Address - Phone:317-384-3491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty