Provider Demographics
NPI:1972834687
Name:OTIS, JOANNA LEE (MS, RDN, CD, CNSC)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:LEE
Last Name:OTIS
Suffix:
Gender:F
Credentials:MS, RDN, CD, CNSC
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:LEE
Other - Last Name:OTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE # 1510
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-333-9501
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:COMPLIANCE MC 2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-8230
Practice Address - Fax:608-262-1636
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2223133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2223-029OtherCERTIFIED DIETITIAN