Healthcare Provider Details

I. General information

NPI: 1326560459
Provider Name (Legal Business Name): LILEEAN MARIE OTHMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 03/20/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 DR MLK ST N SUITE 190
SAINT PETERSBURG FL
33702
US

IV. Provider business mailing address

915 N FRANKLIN ST UNIT 2009
TAMPA FL
33602-3884
US

V. Phone/Fax

Practice location:
  • Phone: 727-576-7600
  • Fax:
Mailing address:
  • Phone: 321-289-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number11038277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: