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NPI Code Detail

MEDICARE: MRS. KELLI WALLACE COTA

MEDICARE: MRS. KELLI WALLACE COTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1224Z00000XOccupational Therapy AssistantOT-A969AR

General Provider Information

NPI Number : 1649667353
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KELLI WALLACE COTA
Provider Business Mailing Address
First Line : 2701 T P WHITE DR
Second Line :
City : JACKSONVILLE
State : AR
Zip : 72076-2514
Country : US
Telephone Number : 501-241-0410
Fax Number : 501-241-0125
Provider Business Practice Location Address
First Line : 2701 T P WHITE DR
Second Line :
City : JACKSONVILLE
State : AR
Zip : 72076-2514
Country : US
Telephone Number : 501-241-0410
Fax Number : 501-241-0125
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/20/2015
Last Update Date : 04/20/2015

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Directions to “ MRS. KELLI WALLACE COTA” Practice Location

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