Healthcare Provider Details

I. General information

NPI: 1871212365
Provider Name (Legal Business Name): CAITLYN ANN CULLARO COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3495 HOFFMAN STREET
PENNEY FARMS FL
32079
US

IV. Provider business mailing address

250 CHERRY RIDGE DR APT 111
JACKSONVILLE FL
32222-2861
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-5994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number19110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: