Provider Demographics
NPI:1164191888
Name:OTTO, PRISCILLA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:MARIE
Last Name:OTTO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:MARIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1102 7TH AVE E
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4450
Mailing Address - Country:US
Mailing Address - Phone:701-572-7262
Mailing Address - Fax:
Practice Address - Street 1:1102 7TH AVE E
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4450
Practice Address - Country:US
Practice Address - Phone:701-572-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR40654163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse