Provider Demographics
NPI:1457708109
Name:OTIS, DANIELLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:DANIELLE
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:SHOULDICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:221 22ND ST S
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-3007
Mailing Address - Country:US
Mailing Address - Phone:269-579-3499
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST STE M-124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5377
Practice Address - Country:US
Practice Address - Phone:269-341-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007780363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical