Healthcare Provider Details

I. General information

NPI: 1245823962
Provider Name (Legal Business Name): COURTNEY KOTEWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2021
Last Update Date: 04/26/2023
Certification Date: 04/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900 PARK PLAZA DRIVE SUITE 150
CERRITOS CA
90703
US

IV. Provider business mailing address

2552 HALL ST SE
GRAND RAPIDS MI
49506-3568
US

V. Phone/Fax

Practice location:
  • Phone: 989-714-7861
  • Fax:
Mailing address:
  • Phone: 989-714-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704270430
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704270430
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: