Provider Demographics
NPI:1497560114
Name:OETTER, ADALYN BRIANNA
Entity type:Individual
Prefix:
First Name:ADALYN
Middle Name:BRIANNA
Last Name:OETTER
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 1:52440 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-6360
Mailing Address - Country:US
Mailing Address - Phone:402-321-6555
Mailing Address - Fax:
Practice Address - Street 1:4306 GROVER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-3831
Practice Address - Country:US
Practice Address - Phone:402-990-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care