Provider Demographics
NPI:1609145788
Name:OTTERSTATTER, CAROLE JENNIFER (R,N)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:JENNIFER
Last Name:OTTERSTATTER
Suffix:
Gender:F
Credentials:R,N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5502
Mailing Address - Country:US
Mailing Address - Phone:585-342-4000
Mailing Address - Fax:585-342-4694
Practice Address - Street 1:125 KINGS HWY S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-5502
Practice Address - Country:US
Practice Address - Phone:585-342-4000
Practice Address - Fax:585-342-4694
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205327-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse