Provider Demographics
NPI:1710964200
Name:OTTEMILLER, SUSAN J (ARNP, DNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:OTTEMILLER
Suffix:
Gender:F
Credentials:ARNP, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5400
Mailing Address - Fax:
Practice Address - Street 1:825 EASTLAKE AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:206-520-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60848345363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCD8723OtherRR MEDICARE GROUP NUMBER
ORP00085410OtherRR MEDICARE PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC GROUP NPI NUMBER
OR161133OtherGROUP NBMC MEDICAID
OR500618060Medicaid
OR0577260001OtherDMERC NUMBER
WA1710964200Medicaid
OR500618060Medicaid
OR500618060Medicaid