Provider Demographics
NPI:1336322544
Name:OTTEY, PEGGY A (CRNP)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:A
Last Name:OTTEY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-3964
Mailing Address - Country:US
Mailing Address - Phone:301-268-5903
Mailing Address - Fax:509-491-3031
Practice Address - Street 1:IDEAL OPTION
Practice Address - Street 2:47 VIRGINIA AVENUE
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502
Practice Address - Country:US
Practice Address - Phone:301-268-5903
Practice Address - Fax:509-491-3031
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-11
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR149658363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD028465300Medicaid
MD171700Y82Medicare PIN