Provider Demographics
NPI:1174674063
Name:OTT, JANA MARLENE (CRNA)
Entity Type:Individual
Prefix:
First Name:JANA
Middle Name:MARLENE
Last Name:OTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:203-688-0715
Practice Address - Fax:475-246-9062
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP100837367500000X
CT11409367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
430027414OtherRAILROAD MEDICARE
88641COtherTX-BLUE SHIELD
TX109955805Medicaid
88641CMedicare PIN
TX420645YK6UMedicare PIN