Provider Demographics
NPI:1790849529
Name:OTTLEY, VERLA R (CNP)
Entity Type:Individual
Prefix:
First Name:VERLA
Middle Name:R
Last Name:OTTLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4360
Mailing Address - Country:US
Mailing Address - Phone:208-523-8844
Mailing Address - Fax:208-529-8684
Practice Address - Street 1:1660 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4360
Practice Address - Country:US
Practice Address - Phone:208-523-8844
Practice Address - Fax:208-529-8684
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-253A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00001006616OtherBLUE SHIELD OF IDAHO
IDNPHK8OtherBLUE CROSS OF IDAHO
ID00001006616OtherBLUE SHIELD OF IDAHO
IDR37164Medicare UPIN