Healthcare Provider Details

I. General information

NPI: 1902238157
Provider Name (Legal Business Name): KRISTIN COLE KETCH COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 NW 150TH TER
EDMOND OK
73013-1525
US

IV. Provider business mailing address

1417 NW 150TH TER
EDMOND OK
73013-1525
US

V. Phone/Fax

Practice location:
  • Phone: 405-831-5893
  • Fax:
Mailing address:
  • Phone: 405-831-5893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number978
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: