Provider Demographics
NPI:1114272747
Name:POTTER, WENDIE
Entity type:Individual
Prefix:MRS
First Name:WENDIE
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 1:8440 OLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-0000
Mailing Address - Country:US
Mailing Address - Phone:631-704-5688
Mailing Address - Fax:
Practice Address - Street 1:8440 OLENBROOK DRIVE
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035
Practice Address - Country:US
Practice Address - Phone:631-704-5688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300288164W00000X
OH182518164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse