Provider Demographics
NPI:1326689878
Name:OTTEN, MATTEA JO (CNM)
Entity Type:Individual
Prefix:
First Name:MATTEA
Middle Name:JO
Last Name:OTTEN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 DUFF AVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50010-5469
Mailing Address - Country:US
Mailing Address - Phone:515-239-4400
Mailing Address - Fax:
Practice Address - Street 1:1015 DUFF AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-5733
Practice Address - Country:US
Practice Address - Phone:515-239-4414
Practice Address - Fax:515-239-4786
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB156350367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE