Provider Demographics
NPI:1285302406
Name:POTTER, MCKENNA M (MS, ATC, LAT)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:M
Last Name:POTTER
Suffix:
Gender:F
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3
Mailing Address - Street 2:
Mailing Address - City:SOMONAUK
Mailing Address - State:IL
Mailing Address - Zip Code:60552-0003
Mailing Address - Country:US
Mailing Address - Phone:815-545-5591
Mailing Address - Fax:
Practice Address - Street 1:704 W ABE ST
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-1167
Practice Address - Country:US
Practice Address - Phone:630-552-3178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL096.0057002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program