Provider Demographics
NPI:1134583255
Name:OTTY, JENNIFER (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:OTTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MARLENE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1704
Mailing Address - Country:US
Mailing Address - Phone:518-801-4135
Mailing Address - Fax:
Practice Address - Street 1:4 MARLENE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1704
Practice Address - Country:US
Practice Address - Phone:518-801-4135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2021-03-01
Deactivation Date:2016-06-09
Deactivation Code:
Reactivation Date:2017-10-18
Provider Licenses
StateLicense IDTaxonomies
AZLP038497164W00000X
NY237870164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse