Healthcare Provider Details

I. General information

NPI: 1700154689
Provider Name (Legal Business Name): NICOLE ANNMARIE KOTASKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2011
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 BRIDGE ST NW #111
SAINT FRANCIS MN
55070-8632
US

IV. Provider business mailing address

4429 231ST CT NW
SAINT FRANCIS MN
55070-8788
US

V. Phone/Fax

Practice location:
  • Phone: 612-240-6601
  • Fax:
Mailing address:
  • Phone: 612-240-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number301
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: