Healthcare Provider Details

I. General information

NPI: 1124283023
Provider Name (Legal Business Name): CAROLYN ELIZABETH OTTO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

3766 N LAKEWOOD AVE 1N
CHICAGO IL
60613-3716
US

V. Phone/Fax

Practice location:
  • Phone: 312-695-9013
  • Fax:
Mailing address:
  • Phone: 917-842-1422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209007148
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: