Provider Demographics
NPI:1063130565
Name:OTIS, TAMMY (MSN,RN,CPN)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:OTIS
Suffix:
Gender:F
Credentials:MSN,RN,CPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CHARL LN
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-9554
Mailing Address - Country:US
Mailing Address - Phone:513-519-9272
Mailing Address - Fax:
Practice Address - Street 1:87 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144-2613
Practice Address - Country:US
Practice Address - Phone:518-449-1142
Practice Address - Fax:518-449-1320
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY831589163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics