Healthcare Provider Details

I. General information

NPI: 1780928341
Provider Name (Legal Business Name): PAULETTE AUDIE MARIE WELLS COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12095 S ELM ST
JENKS OK
74037-3689
US

IV. Provider business mailing address

921 N FIR ST
JENKS OK
74037-2705
US

V. Phone/Fax

Practice location:
  • Phone: 918-808-9749
  • Fax:
Mailing address:
  • Phone: 918-200-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1178
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: