Provider Demographics
NPI:1750531638
Name:OTTENS, NICOLE Y (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:Y
Last Name:OTTENS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1000 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9261
Practice Address - Country:US
Practice Address - Phone:217-258-2551
Practice Address - Fax:217-258-2256
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003351A207Q00000X
IL036-126162207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine