Provider Demographics
NPI:1467266320
Name:OTT, STACY A (RN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:OTT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 YOSEMITE WAY
Mailing Address - Street 2:
Mailing Address - City:WHITEWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57793-3101
Mailing Address - Country:US
Mailing Address - Phone:605-641-6978
Mailing Address - Fax:
Practice Address - Street 1:3200 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-8114
Practice Address - Country:US
Practice Address - Phone:605-355-2500
Practice Address - Fax:605-355-2500
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD-RNR058496163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse