Provider Demographics
NPI:1740341924
Name:OTTLEY SAM, JEUELLE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JEUELLE
Middle Name:M
Last Name:OTTLEY SAM
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:6 PARK CENTER CT
Mailing Address - Street 2:STE 210
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5604
Mailing Address - Country:US
Mailing Address - Phone:443-953-8922
Mailing Address - Fax:855-955-1334
Practice Address - Street 1:7610 CARROLL AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6384
Practice Address - Country:US
Practice Address - Phone:301-891-2077
Practice Address - Fax:301-891-2080
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-03-05
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Provider Licenses
StateLicense IDTaxonomies
MDC0002743363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant