Provider Demographics
NPI:1093100596
Name:OTWELL, LARRY DON (LPN)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DON
Last Name:OTWELL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-4208
Mailing Address - Country:US
Mailing Address - Phone:580-478-7684
Mailing Address - Fax:
Practice Address - Street 1:317 W CHEROKEE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5615
Practice Address - Country:US
Practice Address - Phone:888-573-7792
Practice Address - Fax:888-573-7792
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0046123164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse