Healthcare Provider Details

I. General information

NPI: 1720228679
Provider Name (Legal Business Name): JENNIFER KIMBERLY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E 21ST ST
CLOVIS NM
88101-4442
US

IV. Provider business mailing address

810 E 21ST ST SUITE 6A
CLOVIS NM
88101-4442
US

V. Phone/Fax

Practice location:
  • Phone: 575-763-9517
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2553
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: