Healthcare Provider Details

I. General information

NPI: 1225525108
Provider Name (Legal Business Name): KRISTEN JESSICA GREEN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 N ROCK RD STE 101
WICHITA KS
67226-1341
US

IV. Provider business mailing address

3500 N ROCK RD STE 101
WICHITA KS
67226-1341
US

V. Phone/Fax

Practice location:
  • Phone: 316-440-3316
  • Fax: 888-965-6885
Mailing address:
  • Phone: 316-440-3316
  • Fax: 888-965-6885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberT-04882
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: