Healthcare Provider Details

I. General information

NPI: 1477438422
Provider Name (Legal Business Name): BROOKE LAUREN STEVENS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2669 ENTERPRISE RD
ORANGE CITY FL
32763-8217
US

IV. Provider business mailing address

5103 TAYLOR AVE
PORT ORANGE FL
32127-5425
US

V. Phone/Fax

Practice location:
  • Phone: 321-972-8326
  • Fax:
Mailing address:
  • Phone: 386-285-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20076
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: