Provider Demographics
NPI:1063847135
Name:OTTLEY, AN JALIQUE C
Entity Type:Individual
Prefix:MS
First Name:AN JALIQUE
Middle Name:C
Last Name:OTTLEY
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 1:2419 DAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-4844
Mailing Address - Country:US
Mailing Address - Phone:239-333-9557
Mailing Address - Fax:239-694-5360
Practice Address - Street 1:2419 DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-4844
Practice Address - Country:US
Practice Address - Phone:239-333-9557
Practice Address - Fax:239-694-5360
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No172A00000XOther Service ProvidersDriver
No175F00000XOther Service ProvidersNaturopath
No347C00000XTransportation ServicesPrivate Vehicle