Provider Demographics
NPI:1649603044
Name:OTTO, KIRBY ELIZABETH (APNP)
Entity type:Individual
Prefix:
First Name:KIRBY
Middle Name:ELIZABETH
Last Name:OTTO
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:KIRBY
Other - Middle Name:ELIZABETH
Other - Last Name:KNAPMILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7238
Practice Address - Street 1:100 COUNTY ROAD B
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-7072
Practice Address - Country:US
Practice Address - Phone:920-731-8900
Practice Address - Fax:920-225-1414
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5477-33363L00000X
WI156249-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400102684Medicare Oscar/Certification