Healthcare Provider Details

I. General information

NPI: 1689719148
Provider Name (Legal Business Name): NIKKI LYNN OTT MS RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N ONEIDA ST STE E
APPLETON WI
54911-2082
US

IV. Provider business mailing address

2701 N ONEIDA ST STE E
APPLETON WI
54911-2082
US

V. Phone/Fax

Practice location:
  • Phone: 920-997-8603
  • Fax:
Mailing address:
  • Phone: 920-749-1171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1591-029
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: