Healthcare Provider Details

I. General information

NPI: 1093100596
Provider Name (Legal Business Name): LARRY DON OTWELL LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 W CHEROKEE AVE SUITE B
ENID OK
73701-5615
US

IV. Provider business mailing address

2005 W ELM AVE
ENID OK
73703-4208
US

V. Phone/Fax

Practice location:
  • Phone: 888-573-7792
  • Fax: 888-573-7792
Mailing address:
  • Phone: 580-478-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL0046123
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: