MEDICARE: LYDIAH OTACHI NURSE PRACTITIONER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	11498	MN
2	363LP2300X	Primary Care Nurse Practitioner	11498	MN
3	363LG0600X	Gerontology Nurse Practitioner	11498	MN

General Provider Information

NPI Number	:	1689428070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIAH OTACHI NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	PO BOX 17370
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-0370
Country	:	US
Telephone Number	:	612-471-3791
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 17370
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55117-0370
Country	:	US
Telephone Number	:	612-471-3791
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2024
Last Update Date	:	05/23/2026

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