Provider Demographics
NPI:1114694890
Name:OTTON, NICOLE RUTH (CHA-T)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RUTH
Last Name:OTTON
Suffix:
Gender:F
Credentials:CHA-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 70
Mailing Address - Street 2:
Mailing Address - City:KOYUK
Mailing Address - State:AK
Mailing Address - Zip Code:99753
Mailing Address - Country:US
Mailing Address - Phone:907-963-3311
Mailing Address - Fax:907-963-3610
Practice Address - Street 1:1000 GREG KRUSHEK AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762-9976
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:907-443-3471
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-TOtherCHA-T