Provider Demographics
NPI:1942199641
Name:POTTER, KELLIE LYNN
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYNN
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 1:1211 PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68005-4211
Mailing Address - Country:US
Mailing Address - Phone:402-212-0651
Mailing Address - Fax:
Practice Address - Street 1:1211 PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-4211
Practice Address - Country:US
Practice Address - Phone:402-212-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child