Provider Demographics
NPI:1881644300
Name:OTIS-PEPPER, LONNA KAY (NP)
Entity Type:Individual
Prefix:
First Name:LONNA
Middle Name:KAY
Last Name:OTIS-PEPPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 272801
Mailing Address - Street 2:PO BOX 67000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-2728
Mailing Address - Country:US
Mailing Address - Phone:517-841-6913
Mailing Address - Fax:517-841-6917
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4958
Practice Address - Fax:517-796-6410
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704185283363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4645335Medicaid
MIP00312715OtherRR MEDICARE
MIM73310023Medicare ID - Type UnspecifiedWA FOOTE MEMORIAL
MI4645335Medicaid