Provider Demographics
NPI:1255037065
Name:OTERO, LISSETTE ALEXANDRA (NP)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:ALEXANDRA
Last Name:OTERO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 E 91ST ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2019
Mailing Address - Country:US
Mailing Address - Phone:203-818-3741
Mailing Address - Fax:
Practice Address - Street 1:161 E 91ST ST APT 4A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2019
Practice Address - Country:US
Practice Address - Phone:203-818-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311049363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health