Basic Information
| Provider Information | |||||||||
| NPI: | 1033635925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTIMO | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3495 PIEDMONT RD NE | ||||||||
| Address2: | BLDG 9 1ST FLOOR | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303051717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043650966 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5730 GLENRIDGE DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303285579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042525206 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | RN235965 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | RN235965 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN235965 | 01 | GA | RN LICENSE | OTHER |