Provider Demographics
NPI:1346930500
Name:LOTTIE, HEATHER (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:LOTTIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-1244
Mailing Address - Country:US
Mailing Address - Phone:518-481-2801
Mailing Address - Fax:
Practice Address - Street 1:133 PARK ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1244
Practice Address - Country:US
Practice Address - Phone:518-481-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY672492363L00000X
NY352313363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner