Basic Information
| Provider Information | |||||||||
| NPI: | 1326689878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OTTEN | ||||||||
| FirstName: | MATTEA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1015 DUFF AVE | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500105733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152394414 | ||||||||
| FaxNumber: | 5152394786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | B156350 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | NONE | 01 | NONE | OTHER |