=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992318315
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRISMA OTANEZ FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 08/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4670 GAGE AVE
-----------------------------------------------------
City | BELL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90201-1360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-562-3135
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14419 ARTHUR ST
-----------------------------------------------------
City | OAK HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92344-9507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95014990
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------