Provider Demographics
NPI:1316922081
Name:OTT, SUSAN (ARNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:OTT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CRYSTAL BEACH DR STE 137C
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-3588
Mailing Address - Country:US
Mailing Address - Phone:850-460-7090
Mailing Address - Fax:850-460-9073
Practice Address - Street 1:155 CRYSTAL BEACH DR STE 137C
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3588
Practice Address - Country:US
Practice Address - Phone:850-460-7090
Practice Address - Fax:850-460-7093
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3075942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302337100Medicaid
FLE0635XMedicare PIN
S54519Medicare UPIN