=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336322544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEGGY A OTTEY CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2007
-----------------------------------------------------
Last Update Date | 01/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | IDEAL OPTION 47 VIRGINIA AVENUE
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-268-5903
-----------------------------------------------------
Fax | 509-491-3031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 VIRGINIA AVE
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21502-3964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-268-5903
-----------------------------------------------------
Fax | 509-491-3031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | R149658
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------