Healthcare Provider Details

I. General information

NPI: 1053800201
Provider Name (Legal Business Name): KATHLEEN KAY OTTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 N POPLAR AVE
TEA SD
57064-2152
US

IV. Provider business mailing address

131 N POPLAR AVE
TEA SD
57064-2152
US

V. Phone/Fax

Practice location:
  • Phone: 605-498-2702
  • Fax: 605-498-2702
Mailing address:
  • Phone: 605-498-2700
  • Fax: 605-498-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR018685
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: