Healthcare Provider Details

I. General information

NPI: 1972834687
Provider Name (Legal Business Name): JOANNA LEE OTIS MS, RDN, CD, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOANNA LEE OTIS

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE COMPLIANCE MC 2433
MADISON WI
53792-0001
US

IV. Provider business mailing address

600 HIGHLAND AVE # 1510
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-8230
  • Fax: 608-262-1636
Mailing address:
  • Phone: 608-333-9501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2223
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: