Provider Demographics
NPI:1265495915
Name:OTT, OLIVIA D (CNM, CRNP)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:D
Last Name:OTT
Suffix:
Gender:F
Credentials:CNM, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 CAMPBELL STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701
Mailing Address - Country:US
Mailing Address - Phone:570-327-9900
Mailing Address - Fax:570-327-9400
Practice Address - Street 1:904 CAMPBELL STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701
Practice Address - Country:US
Practice Address - Phone:570-327-9900
Practice Address - Fax:570-327-9400
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008498L367A00000X
PAVP002098G363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S78422Medicare UPIN
PA026153Medicare ID - Type Unspecified