Provider Demographics
NPI:1629085576
Name:OTTLEY, LINDA LAVERNE (NP)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:LAVERNE
Last Name:OTTLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:LAVERNE
Other - Last Name:RUSTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:8472 VIA SONOMA UNIT 30
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-2735
Mailing Address - Country:US
Mailing Address - Phone:760-212-5172
Mailing Address - Fax:
Practice Address - Street 1:632 BROADWAY PH
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2614
Practice Address - Country:US
Practice Address - Phone:800-731-4254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8832363LF0000X, 363LA2200X
TXAP104217363L00000X
MN5647363L00000X
CT14443363L00000X
OKR0132242363L00000X
MARN2310658363L00000X
FLAPRN11022481363LF0000X
PASP033398363LF0000X
MDR088414363LF0000X
GARN286333363LF0000X
NV879334363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP8832Medicare UPIN
CAS47876Medicare ID - Type Unspecified