Provider Demographics
NPI:1689720047
Name:OTIS, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:OTIS
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 1:3118 LEWELLING CT
Mailing Address - Street 2:
Mailing Address - City:KODAK
Mailing Address - State:TN
Mailing Address - Zip Code:37764-1683
Mailing Address - Country:US
Mailing Address - Phone:865-933-1121
Mailing Address - Fax:
Practice Address - Street 1:227 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-3838
Practice Address - Country:US
Practice Address - Phone:865-453-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000152532163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health