Healthcare Provider Details

I. General information

NPI: 1497388797
Provider Name (Legal Business Name): BROOKE OTTMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE CARSTENSEN

II. Dates (important events)

Enumeration Date: 02/15/2020
Last Update Date: 05/02/2020
Certification Date: 05/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10123 SE MARKET ST
PORTLAND OR
97216-2532
US

IV. Provider business mailing address

10123 SE MARKET ST
PORTLAND OR
97216-2532
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61057277
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number201141939RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61057326
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202003090NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: