Healthcare Provider Details

I. General information

NPI: 1699945519
Provider Name (Legal Business Name): GWYNN PARDUE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 W MAIN ST
YADKINVILLE NC
27055-7807
US

IV. Provider business mailing address

1048 GRALYN DR
HAMPTONVILLE NC
27020-8277
US

V. Phone/Fax

Practice location:
  • Phone: 336-679-8863
  • Fax:
Mailing address:
  • Phone: 336-468-1904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4592
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: