Provider Demographics
NPI:1053577163
Name:POTTER, MARIANNE ERVIN (ANP-BC)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:ERVIN
Last Name:POTTER
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:ERVIN
Other - Last Name:VESTERFELT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP-BC
Mailing Address - Street 1:51291 MURRAY HILL DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1026
Mailing Address - Country:US
Mailing Address - Phone:248-345-4175
Mailing Address - Fax:
Practice Address - Street 1:25500 MEADOWBROOK RD STE 230
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1882
Practice Address - Country:US
Practice Address - Phone:248-345-4175
Practice Address - Fax:248-692-4356
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195880363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health