Provider Demographics
NPI:1467095729
Name:OTT, KATIE ANN (RD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANN
Last Name:OTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1552 COFFEE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3122
Mailing Address - Country:US
Mailing Address - Phone:209-248-7168
Mailing Address - Fax:209-846-9641
Practice Address - Street 1:1552 COFFEE RD STE 200
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3122
Practice Address - Country:US
Practice Address - Phone:209-248-7168
Practice Address - Fax:209-846-9641
Is Sole Proprietor?:No
Enumeration Date:2019-10-18
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86062158133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered