1043259617 NPI number — JENNIFER H OTTO N.P.

Table of content: SANDRA ELIZABETH CHARNLEY APRN, FNP-BC (NPI 1528570983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043259617 NPI number — JENNIFER H OTTO N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTO
Provider First Name:
JENNIFER
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
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:
1043259617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 E RIVER RD
Provider Second Line Business Mailing Address:
350
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85718-5999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-519-7775
Provider Business Mailing Address Fax Number:
520-519-7760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 E TANGERINE RD
Provider Second Line Business Practice Location Address:
STE 157
Provider Business Practice Location Address City Name:
ORO VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85755-6216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-229-2095
Provider Business Practice Location Address Fax Number:
520-229-8501
Provider Enumeration Date:
06/06/2006

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: 363L00000X , with the licence number:  582818 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 417635 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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