Provider Demographics
NPI:1962975433
Name:POTTER-KITCHENS, LAUREN ASHLEY
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ASHLEY
Last Name:POTTER-KITCHENS
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 1:4075 SUNRISE FARMS RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3780
Mailing Address - Country:US
Mailing Address - Phone:904-509-4861
Mailing Address - Fax:
Practice Address - Street 1:4075 SUNRISE FARMS RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3780
Practice Address - Country:US
Practice Address - Phone:904-509-4861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0153193003747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015319300Medicaid