Healthcare Provider Details

I. General information

NPI: 1154537611
Provider Name (Legal Business Name): KIPP ASHLEY ROBERTS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4934 NE 123RD LN
OXFORD FL
34484-9630
US

IV. Provider business mailing address

4934 NE 123RD LN
OXFORD FL
34484-9630
US

V. Phone/Fax

Practice location:
  • Phone: 352-466-2143
  • Fax:
Mailing address:
  • Phone: 352-466-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA12429
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberKY-A3608
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: