Healthcare Provider Details

I. General information

NPI: 1952824716
Provider Name (Legal Business Name): ELLEN OTTO APRN-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 AVE B SUITE B QUICK CARE
SCOTTSBLUFF NE
69361
US

IV. Provider business mailing address

2197 ROAD 38
YODER WY
82244-8825
US

V. Phone/Fax

Practice location:
  • Phone: 308-630-0800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number112284
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: