Healthcare Provider Details

I. General information

NPI: 1063939643
Provider Name (Legal Business Name): JANELLE TRAN COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 COPPER AVE NE
ALBUQUERQUE NM
87108-1473
US

IV. Provider business mailing address

1733 SHIRLEY ST NE
ALBUQUERQUE NM
87112-4444
US

V. Phone/Fax

Practice location:
  • Phone: 505-266-5557
  • Fax: 505-266-5545
Mailing address:
  • Phone: 505-615-5220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3614
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: