Provider Demographics
NPI:1306110838
Name:POTTER, STACEY L (LMT, MTI, BS)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:POTTER
Suffix:
Gender:F
Credentials:LMT, MTI, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 N MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6957
Mailing Address - Country:US
Mailing Address - Phone:505-701-4164
Mailing Address - Fax:
Practice Address - Street 1:313 N MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6957
Practice Address - Country:US
Practice Address - Phone:505-701-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM# 7128174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist