Provider Demographics
NPI:1194139683
Name:OTIENO, BETTY (RN)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:OTIENO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:BETTY
Other - Middle Name:
Other - Last Name:OTIENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:4392 CHATUGE DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-1866
Mailing Address - Country:US
Mailing Address - Phone:678-908-8731
Mailing Address - Fax:678-908-8731
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:678-212-6343
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN084632101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health