Healthcare Provider Details

I. General information

NPI: 1164516167
Provider Name (Legal Business Name): KATHLEEN MARIE OTIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

313 E WILLOW ST
SYRACUSE NY
13203-1976
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-4400
  • Fax:
Mailing address:
  • Phone: 315-378-4869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number299913-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: