Provider Demographics
NPI:1487403770
Name:OTTER, LORI
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:OTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6050 STATE ROUTE 26
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-8067
Mailing Address - Country:US
Mailing Address - Phone:315-794-5219
Mailing Address - Fax:
Practice Address - Street 1:6050 STATE ROUTE 26
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-8067
Practice Address - Country:US
Practice Address - Phone:315-794-5219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY552998163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse