Healthcare Provider Details

I. General information

NPI: 1184964843
Provider Name (Legal Business Name): GLORIA JEAN PUCKETT COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15051 HARMONY HILLS LN
ABINGDON VA
24211-7661
US

IV. Provider business mailing address

15051 HARMONY HILLS LN
ABINGDON VA
24211-7661
US

V. Phone/Fax

Practice location:
  • Phone: 276-451-2590
  • Fax: 276-619-2488
Mailing address:
  • Phone: 276-451-2590
  • Fax: 276-619-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000701
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: