Provider Demographics
NPI:1255711032
Name:OTTER, ROSE (IBCLC)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:OTTER
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 SE MORRISON ST
Mailing Address - Street 2:APT 220
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3191
Mailing Address - Country:US
Mailing Address - Phone:541-646-5355
Mailing Address - Fax:
Practice Address - Street 1:3340 SE MORRISON ST
Practice Address - Street 2:APT 220
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3191
Practice Address - Country:US
Practice Address - Phone:541-646-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL-56283174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN