Provider Demographics
NPI:1518456177
Name:OTTLEY, NICHOLAS (AUD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:OTTLEY
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8656 N CEDAR AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-4803
Mailing Address - Country:US
Mailing Address - Phone:760-560-8791
Mailing Address - Fax:
Practice Address - Street 1:1351 E SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3342
Practice Address - Country:US
Practice Address - Phone:559-432-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program