Provider Demographics
NPI:1972197572
Name:OTTO, LORI A
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
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 1:5788 KUNGLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44203-7839
Mailing Address - Country:US
Mailing Address - Phone:330-606-6254
Mailing Address - Fax:
Practice Address - Street 1:5788 KUNGLE RD
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44203-7839
Practice Address - Country:US
Practice Address - Phone:330-606-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH301823747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30182Medicaid