Healthcare Provider Details

I. General information

NPI: 1275190332
Provider Name (Legal Business Name): RANI E HALLIDAY COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FLORA LAKE CIR
SAINT AUGUSTINE FL
32095-8962
US

IV. Provider business mailing address

214 FLORA LAKE CIR
SAINT AUGUSTINE FL
32095-8962
US

V. Phone/Fax

Practice location:
  • Phone: 480-600-5728
  • Fax:
Mailing address:
  • Phone: 480-600-5728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number16490
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: