1942297924 NPI number — MS. MICHELE L OTT

Table of content: MS. MICHELE L OTT (NPI 1942297924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942297924 NPI number — MS. MICHELE L OTT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTT
Provider First Name:
MICHELE
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942297924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
141 TRINITY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST MARIES
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83861-9342
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-686-1110
Provider Business Mailing Address Fax Number:
208-686-0242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1115 B STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLUMMER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83851-0388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-686-1931
Provider Business Practice Location Address Fax Number:
208-686-0242
Provider Enumeration Date:
10/04/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 126800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)