Healthcare Provider Details

I. General information

NPI: 1891902482
Provider Name (Legal Business Name): PENNY SUE EMMONS COTA-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 PIONEER PKWY
JOHNSTON IA
50131-1569
US

IV. Provider business mailing address

7074 HICKORY LN
URBANDALE IA
50322-1891
US

V. Phone/Fax

Practice location:
  • Phone: 515-270-2205
  • Fax: 515-276-0140
Mailing address:
  • Phone: 515-334-9528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number00034
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: