Healthcare Provider Details

I. General information

NPI: 1366179533
Provider Name (Legal Business Name): ASHLEY KARINA BONILLA COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 08/06/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N WALTON BLVD STE 2AND4
BENTONVILLE AR
72712-4548
US

IV. Provider business mailing address

47 TOMINO WAY
HOT SPRINGS VILLAGE AR
71909-2780
US

V. Phone/Fax

Practice location:
  • Phone: 479-250-9838
  • Fax:
Mailing address:
  • Phone: 501-204-9233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT-A1856
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: