Healthcare Provider Details

I. General information

NPI: 1952868895
Provider Name (Legal Business Name): IVANA LAZIC COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 HIDDEN OAKS DR
LADY LAKE FL
32159-5150
US

IV. Provider business mailing address

130 HIDDEN OAKS DR
LADY LAKE FL
32159-5150
US

V. Phone/Fax

Practice location:
  • Phone: 407-969-5799
  • Fax:
Mailing address:
  • Phone: 407-969-5799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA17094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: