Healthcare Provider Details

I. General information

NPI: 1700173788
Provider Name (Legal Business Name): MIKAELA ESAU OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WOODLAND DR
COVENTRY RI
02816-6716
US

IV. Provider business mailing address

10 WOODLAND DR
COVENTRY RI
02816-6716
US

V. Phone/Fax

Practice location:
  • Phone: 401-826-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOT01229
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: