Provider Demographics
NPI:1780568295
Name:OTTO, HEATHER ROSE (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ROSE
Last Name:OTTO
Suffix:
Gender:X
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8504 SE MIDDLE WAY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-2727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6700 SW 105TH AVE STE 303
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-8825
Practice Address - Country:US
Practice Address - Phone:503-218-3924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10048385363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty