Healthcare Provider Details

I. General information

NPI: 1396114302
Provider Name (Legal Business Name): THERESA BROOKS KOTLAR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA MALION RN

II. Dates (important events)

Enumeration Date: 09/20/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7174 COLONIAL PLACE
RAVENNA OH
44266
US

IV. Provider business mailing address

7174 COLONIAL PLACE
RAVENNA OH
44268
US

V. Phone/Fax

Practice location:
  • Phone: 330-906-3331
  • Fax:
Mailing address:
  • Phone: 330-906-3331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number213262
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN213262
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number213262
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: