Healthcare Provider Details

I. General information

NPI: 1235092271
Provider Name (Legal Business Name): EDWIN COTTRELL SR. VETERAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: EARLETEYA COTTRELL RN, BSN, MBA, NASM

II. Dates (important events)

Enumeration Date: 12/05/2025
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 STONECREST CONCOURSE
STONECREST GA
30038-6901
US

IV. Provider business mailing address

8016 WHITE OAK LOOP
STONECREST GA
30038-3306
US

V. Phone/Fax

Practice location:
  • Phone: 470-854-0656
  • Fax:
Mailing address:
  • Phone: 470-854-0656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number171400000X
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: