Provider Demographics
NPI:1386983021
Name:POTTER, SHAROLYN
Entity type:Individual
Prefix:
First Name:SHAROLYN
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 1:4323 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-2830
Mailing Address - Country:US
Mailing Address - Phone:757-377-2790
Mailing Address - Fax:
Practice Address - Street 1:4323 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-2830
Practice Address - Country:US
Practice Address - Phone:757-377-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306001715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant