Provider Demographics
NPI:1033770698
Name:OTTO, TIFFANY (FAMILY NURSE PRACTIT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:FAMILY NURSE PRACTIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WESTBOURNE PKWY
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1735
Mailing Address - Country:US
Mailing Address - Phone:860-713-3637
Mailing Address - Fax:
Practice Address - Street 1:27O FARMINGTON AVENUE
Practice Address - Street 2:# 309
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032
Practice Address - Country:US
Practice Address - Phone:860-677-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily