Provider Demographics
NPI:1942780507
Name:OTTO, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2758 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47542-9529
Mailing Address - Country:US
Mailing Address - Phone:812-630-5518
Mailing Address - Fax:
Practice Address - Street 1:1805 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4326
Practice Address - Country:US
Practice Address - Phone:812-254-7545
Practice Address - Fax:812-254-5989
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012595363LF0000X, 363LP2300X
VA0024179430363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024179430OtherVIRGINIA NURSING BOARD