Provider Demographics
NPI:1285771048
Name:LOTTEN, MARY LOUISE (RN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:LOTTEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 E ELDER DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1835
Mailing Address - Country:US
Mailing Address - Phone:928-526-8946
Mailing Address - Fax:
Practice Address - Street 1:3285 E SPARROW AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7794
Practice Address - Country:US
Practice Address - Phone:928-527-6118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN095491163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ685894Medicaid