Healthcare Provider Details

I. General information

NPI: 1215850672
Provider Name (Legal Business Name): CARRIE OTTERNESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12222 W BRIDGER BAY DR
STAR ID
83669-5081
US

IV. Provider business mailing address

224 ANDERSON ST
CALDWELL ID
83605-3910
US

V. Phone/Fax

Practice location:
  • Phone: 208-391-2773
  • Fax:
Mailing address:
  • Phone: 360-523-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5281027
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: