Provider Demographics
NPI:1063038909
Name:OTT, KELLI JEANNINE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JEANNINE
Last Name:OTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95351-3316
Mailing Address - Country:US
Mailing Address - Phone:209-341-0718
Mailing Address - Fax:
Practice Address - Street 1:609 5TH ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-3316
Practice Address - Country:US
Practice Address - Phone:209-341-0718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider