Healthcare Provider Details

I. General information

NPI: 1629085576
Provider Name (Legal Business Name): LINDA LAVERNE OTTLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LINDA LAVERNE RUSTIN NP

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 BROADWAY PH
NEW YORK NY
10012-2614
US

IV. Provider business mailing address

8472 VIA SONOMA UNIT 30
LA JOLLA CA
92037-2735
US

V. Phone/Fax

Practice location:
  • Phone: 800-731-4254
  • Fax:
Mailing address:
  • Phone: 760-212-5172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8832
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP104217
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5647
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14443
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0132242
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2310658
License Number StateMA
# 7
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11022481
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number8832
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP033398
License Number StatePA
# 10
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR088414
License Number StateMD
# 11
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN286333
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number879334
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: