Healthcare Provider Details

I. General information

NPI: 1386120301
Provider Name (Legal Business Name): KARA A OTT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 ROBERTSON BLVD
WALTERBORO SC
29488-2787
US

IV. Provider business mailing address

7314 FREEDOM RD
BRANCHVILLE SC
29432-2217
US

V. Phone/Fax

Practice location:
  • Phone: 843-782-2217
  • Fax:
Mailing address:
  • Phone: 803-290-4816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22032
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: