Provider Demographics
NPI:1922099696
Name:OTTENBACHER, MELISSA R (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:R
Last Name:OTTENBACHER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:RENEE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP FNP MSN
Mailing Address - Street 1:9951 MICKELBERRY RD NW
Mailing Address - Street 2:STE 101
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8309
Mailing Address - Country:US
Mailing Address - Phone:360-692-9362
Mailing Address - Fax:360-392-6214
Practice Address - Street 1:450 S KITSAP BLVD
Practice Address - Street 2:STE 2300
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3773
Practice Address - Country:US
Practice Address - Phone:360-895-0216
Practice Address - Fax:360-895-7919
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60103856363LP0200X
WARN00167987364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9662412Medicaid
WARN00167987OtherRN
WAAP60103856OtherARNP LICENSE
WAMO2021222OtherDEA
WA9662412Medicaid
WAG8884783Medicare PIN