Healthcare Provider Details

I. General information

NPI: 1578636445
Provider Name (Legal Business Name): PATRICIA ANN KOERNER O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17352 VINEWOOD AVE
TUSTIN CA
92780-2551
US

IV. Provider business mailing address

17352 VINEWOOD AVE
TUSTIN CA
92780-2551
US

V. Phone/Fax

Practice location:
  • Phone: 714-730-1525
  • Fax: 714-730-0369
Mailing address:
  • Phone: 714-730-1525
  • Fax: 714-730-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License NumberOT650
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT650
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: