Healthcare Provider Details

I. General information

NPI: 1790413979
Provider Name (Legal Business Name): ALEXANDRIA RAE WALENZ COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/15/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N DIERS AVE STE 300
GRAND ISLAND NE
68803-4985
US

IV. Provider business mailing address

1624 JERRY DR
GRAND ISLAND NE
68803-5021
US

V. Phone/Fax

Practice location:
  • Phone: 308-382-0344
  • Fax: 308-382-3241
Mailing address:
  • Phone: 402-707-0399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: