Provider Demographics
NPI:1164973962
Name:OTTO, LEEANN
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:OTTO
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 1:42-66 NORTH ST.
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856
Mailing Address - Country:US
Mailing Address - Phone:607-865-5220
Mailing Address - Fax:607-865-9211
Practice Address - Street 1:88 GRISWOLD ST
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856
Practice Address - Country:US
Practice Address - Phone:607-865-5220
Practice Address - Fax:607-865-9211
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659932163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool