Provider Demographics
NPI:1255997086
Name:POTTER, KENDRA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:RAE
Last Name:POTTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 FORT HENRY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2227
Mailing Address - Country:US
Mailing Address - Phone:423-726-2672
Mailing Address - Fax:423-406-1399
Practice Address - Street 1:4221 FORT HENRY DR STE 1
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663-2227
Practice Address - Country:US
Practice Address - Phone:423-726-2672
Practice Address - Fax:423-406-1399
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008946363A00000X
TN363A00000X
TN4173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant