Basic Information
| Provider Information | |||||||||
| NPI: | 1770137580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OTWORTH | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043991507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043991507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2019 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 103703 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0363494 | 05 | OH | MEDICAID | 1770137580 | 05 | WV | MEDICAID | 7100616310 | 05 | KY | MEDICAID |