Provider Demographics
NPI:1285669705
Name:OTIS, ANTOINETTE NICOLE
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:NICOLE
Last Name:OTIS
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 1:1048 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2844
Mailing Address - Country:US
Mailing Address - Phone:614-308-2642
Mailing Address - Fax:
Practice Address - Street 1:1048 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2844
Practice Address - Country:US
Practice Address - Phone:614-308-2642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2550109Medicaid