Healthcare Provider Details

I. General information

NPI: 1063130565
Provider Name (Legal Business Name): TAMMY OTIS MSN,RN,CPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 WASHINGTON ST
RENSSELAER NY
12144-2613
US

IV. Provider business mailing address

10 CHARL LN
TROY NY
12180-9554
US

V. Phone/Fax

Practice location:
  • Phone: 518-449-1142
  • Fax: 518-449-1320
Mailing address:
  • Phone: 513-519-9272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number831589
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: