Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 10085 | WI |
NPI | 1003456823 |
---|---|
Provider Name | Jacqueline Ann Ots |
First Address | Green Bay, WI 54311-8320 |
Second Address | Green Bay, WI 54311-4240 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/01/2020 |
Last Update Date | 05/06/2020 |