Healthcare Provider Details

I. General information

NPI: 1780423343
Provider Name (Legal Business Name): VIVIAN OTIENDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2024
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 MELODY ST
LA VERNE CA
91750-3228
US

IV. Provider business mailing address

4121 MELODY ST
LA VERNE CA
91750-3228
US

V. Phone/Fax

Practice location:
  • Phone: 316-250-9897
  • Fax:
Mailing address:
  • Phone: 316-250-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number53-83182-052
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number302005
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95392476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: