Healthcare Provider Details

I. General information

NPI: 1831329416
Provider Name (Legal Business Name): NIKKI DIANE LYNCH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR3 BOX 108
MCLEANSBORO IL
62859
US

IV. Provider business mailing address

RR 3 BOX 108
MC LEANSBORO IL
62859-9538
US

V. Phone/Fax

Practice location:
  • Phone: 618-757-2267
  • Fax:
Mailing address:
  • Phone: 618-757-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057.003116
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: