Healthcare Provider Details

I. General information

NPI: 1194265744
Provider Name (Legal Business Name): BETHANY GRACE AVILA OTTE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CONANT ST STE 200
BEVERLY MA
01915-1659
US

IV. Provider business mailing address

152 CONANT ST STE 200
BEVERLY MA
01915-1659
US

V. Phone/Fax

Practice location:
  • Phone: 978-922-2226
  • Fax:
Mailing address:
  • Phone: 978-922-2226
  • Fax: 978-922-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95104464
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95006063
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN2367980
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: