Healthcare Provider Details

I. General information

NPI: 1043624984
Provider Name (Legal Business Name): MARILYN OTUAGOMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 WOODWARD ST APT 224
AUSTIN TX
78704-7455
US

IV. Provider business mailing address

701 WOODWARD ST APT 224
AUSTIN TX
78704-7455
US

V. Phone/Fax

Practice location:
  • Phone: 512-825-3121
  • Fax:
Mailing address:
  • Phone: 512-825-3121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: