Provider Demographics
NPI:1396171468
Name:POTTER, KELLI LYNN (CSFA)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:LYNN
Last Name:POTTER
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8736 RANCHO CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 W CRYSTAL LAKE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-4435
Practice Address - Country:US
Practice Address - Phone:407-254-2549
Practice Address - Fax:407-849-6882
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
120940246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant