Provider Demographics
NPI:1750355798
Name:OTT, STEFANIE L (CRNA)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:L
Last Name:OTT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5520
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-0520
Mailing Address - Country:US
Mailing Address - Phone:610-954-5810
Mailing Address - Fax:610-954-5490
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:610-954-5810
Practice Address - Fax:610-954-5480
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-538722163W00000X
PA073904367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2626490000OtherIBC
PA97452OtherGEISINGER
PA1789399OtherHIGHMARK BLUE SHIELD
PA1550240OtherGATEWAY
PA1789399OtherFIRST PRIORITY
PA11754805OtherCAQH
PA9426441OtherAETNA
PA1023332060003Medicaid
PA50055232OtherCAPITAL ADVANTAGE
PA97452OtherGEISINGER
PA11754805OtherCAQH
PA1023332060003Medicaid