Healthcare Provider Details

I. General information

NPI: 1467934646
Provider Name (Legal Business Name): WYKEIA MONIQUE SANDERS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 E NIZHONI BLVD
GALLUP NM
87301-5794
US

IV. Provider business mailing address

586 PENAL FARM RD
SIBLEY LA
71073-3053
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9551
  • Fax:
Mailing address:
  • Phone: 318-834-6222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number214349
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4279
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: