Provider Demographics
NPI:1255971131
Name:POTTER, CASEY LYNN
Entity type:Individual
Prefix:
First Name:CASEY
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 1:68 MCDREAMY CT
Mailing Address - Street 2:
Mailing Address - City:RINEYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40162-8761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 EAAT CHESTNUT STREET
Practice Address - Street 2:LEVEL 5A
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-7450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3014081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner