Provider Demographics
NPI:1518326453
Name:OTERO, JOHNHANNA JENNYFFER
Entity Type:Individual
Prefix:
First Name:JOHNHANNA
Middle Name:JENNYFFER
Last Name:OTERO
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 1:58A E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2481
Mailing Address - Country:US
Mailing Address - Phone:631-470-6169
Mailing Address - Fax:
Practice Address - Street 1:58A E 13TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2481
Practice Address - Country:US
Practice Address - Phone:631-470-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2185275174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist