Healthcare Provider Details

I. General information

NPI: 1811641723
Provider Name (Legal Business Name): ANNA KATHRYN BAIONI COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 GALAXIE DR
JACKSON MS
39206-4335
US

IV. Provider business mailing address

2144 LAKESHORE DR APT 7C
RIDGELAND MS
39157-1028
US

V. Phone/Fax

Practice location:
  • Phone: 662-714-3122
  • Fax: 888-228-1594
Mailing address:
  • Phone: 662-588-2295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA3710
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: