Healthcare Provider Details

I. General information

NPI: 1376102160
Provider Name (Legal Business Name): KARINE OTTEN APN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 1010
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

909 NEWBERRY AVE
LA GRANGE PARK IL
60526-1659
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5904
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209.013567
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: