Provider Demographics
NPI:1164744231
Name:OTTER, MARINA MARIE
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:MARIE
Last Name:OTTER
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 1:2707 N FRUITLAND LN APT C15
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-9374
Mailing Address - Country:US
Mailing Address - Phone:208-664-9407
Mailing Address - Fax:
Practice Address - Street 1:2707 N FRUITLAND LN APT C15
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-9374
Practice Address - Country:US
Practice Address - Phone:208-664-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker