Healthcare Provider Details

I. General information

NPI: 1295840783
Provider Name (Legal Business Name): NANCY LORENE OTT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 UNIVERSITY AVE SE
MINNEAPOLIS MN
55414-3205
US

IV. Provider business mailing address

400 STINSON BLVD PROVIDER ENROLLMENT
MINNEAPOLIS MN
55413
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-2350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number29631
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: