Provider Demographics
NPI:1174911713
Name:OTT, KIMBERLY A (FNP-C)
Entity type:Individual
Prefix:MR
First Name:KIMBERLY
Middle Name:A
Last Name:OTT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10342 N 100 W
Mailing Address - Street 2:
Mailing Address - City:WHEATFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46392-9704
Mailing Address - Country:US
Mailing Address - Phone:219-707-1128
Mailing Address - Fax:
Practice Address - Street 1:28800 RYAN RD SUITE 320
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092
Practice Address - Country:US
Practice Address - Phone:586-620-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28143248A363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care