Healthcare Provider Details

I. General information

NPI: 1316106479
Provider Name (Legal Business Name): DARYL GLEN OTTAWAY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 STATE STREET ROOM 249
SALEM OR
97301
US

IV. Provider business mailing address

PO BOX 14350 1776 MILITIA WAY
SALEM OR
97309-5047
US

V. Phone/Fax

Practice location:
  • Phone: 503-584-2284
  • Fax: 503-584-2293
Mailing address:
  • Phone: 503-584-2284
  • Fax: 503-584-2293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number200340189RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: