Healthcare Provider Details

I. General information

NPI: 1538420138
Provider Name (Legal Business Name): TANQUERAE KISSY-VIRGINIA COLE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 N HANLEY RD
BERKELEY MO
63134-2710
US

IV. Provider business mailing address

1218 SELLS AVE
SAINT LOUIS MO
63147-1506
US

V. Phone/Fax

Practice location:
  • Phone: 314-521-7471
  • Fax:
Mailing address:
  • Phone: 314-642-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2010026845
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: