Provider Demographics
NPI:1881204535
Name:OTTER, MARIEL VERONICA (DNP, CRNP-MH)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:VERONICA
Last Name:OTTER
Suffix:
Gender:F
Credentials:DNP, CRNP-MH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5022 CAMPBELL BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5022 CAMPBELL BLVD STE L
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-4969
Practice Address - Country:US
Practice Address - Phone:443-442-1568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR206504363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty