Healthcare Provider Details

I. General information

NPI: 1902373996
Provider Name (Legal Business Name): KELLEE D FLYNN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLEE D FRIEND COTA

II. Dates (important events)

Enumeration Date: 10/27/2018
Last Update Date: 10/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11281 HIGHWAY U
ODESSA MO
64076-6269
US

IV. Provider business mailing address

11281 HIGHWAY U
ODESSA MO
64076-6269
US

V. Phone/Fax

Practice location:
  • Phone: 806-673-0000
  • Fax:
Mailing address:
  • Phone: 806-673-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2010031975
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: