Basic Information
Provider Information | |||||||||
NPI: | 1669814885 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POTEET | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNP, BSN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NORRIS | ||||||||
OtherFirstName: | TIFFANY | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 700 ACKERMAN RD | ||||||||
Address2: | SUITE 570 | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432021559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6146856567 | ||||||||
FaxNumber: | 6142937221 | ||||||||
Practice Location | |||||||||
Address1: | 452 W 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432101240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142935502 | ||||||||
FaxNumber: | 6142934726 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2013 | ||||||||
LastUpdateDate: | 05/02/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | APRN.CNP.14313 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
ID | Type | State | Issuer | Description | 0135551 | 05 | OH |   | MEDICAID |