=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518326453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNHANNA JENNYFFER OTERO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2016
-----------------------------------------------------
Last Update Date | 02/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 58A E 13TH ST
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-2481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-6169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 58A E 13TH ST
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-2481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-470-6169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 2185275
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------