Healthcare Provider Details

I. General information

NPI: 1821204975
Provider Name (Legal Business Name): SHARON M LAZENBY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHARON M PALMER COTA/L

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10506 RIVERSIDE RD
PORT CHARLOTTE FL
33981-5128
US

IV. Provider business mailing address

10506 RIVERSIDE RD
PORT CHARLOTTE FL
33981-5128
US

V. Phone/Fax

Practice location:
  • Phone: 941-704-8451
  • Fax: 941-870-0876
Mailing address:
  • Phone: 941-704-8451
  • Fax: 941-807-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA359
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: