Healthcare Provider Details

I. General information

NPI: 1467095729
Provider Name (Legal Business Name): KATIE ANN OTT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1552 COFFEE RD STE 200
MODESTO CA
95355-3122
US

IV. Provider business mailing address

1001 SYLVAN AVE STE A
MODESTO CA
95350-1699
US

V. Phone/Fax

Practice location:
  • Phone: 209-248-7168
  • Fax: 209-846-9641
Mailing address:
  • Phone: 209-248-7168
  • Fax: 209-846-9641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86062158
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: