1740579028 NPI number — MISS SANDRA LEE OTTO CNP

Table of content: MISS SANDRA LEE OTTO CNP (NPI 1740579028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740579028 NPI number — MISS SANDRA LEE OTTO CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTO
Provider First Name:
SANDRA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OTTO
Provider Other First Name:
SANDRA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
ACNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1740579028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 EUCLID AVE
Provider Second Line Business Mailing Address:
J4-134
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44195-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-444-2200
Provider Business Mailing Address Fax Number:
216-445-3117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9500 EUCLID AVE
Provider Second Line Business Practice Location Address:
J4-134
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44195-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-444-2200
Provider Business Practice Location Address Fax Number:
216-445-3117
Provider Enumeration Date:
04/07/2011

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: 363LA2100X , with the licence number:  COA.12283-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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