Provider Demographics
NPI:1255943775
Name:OTTUSCH, STEPHANIE MARIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:OTTUSCH
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 1:5055 E BROADWAY BLVD STE A100
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3629
Mailing Address - Country:US
Mailing Address - Phone:520-795-4783
Mailing Address - Fax:520-547-5797
Practice Address - Street 1:5555 E 5TH ST STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2415
Practice Address - Country:US
Practice Address - Phone:520-886-4181
Practice Address - Fax:520-721-7536
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201141583RN163W00000X
AZ288359363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201141583RNOtherOREGON STATE BOARD OF NURSING