Healthcare Provider Details

I. General information

NPI: 1982722922
Provider Name (Legal Business Name): MADONNA MARIAN MALACARNE- COOKE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 HARRISON AVE
CENTRALIA WA
98531-4568
US

IV. Provider business mailing address

204 E HWY K PO BOX 128
LADDONIA MO
63352-0128
US

V. Phone/Fax

Practice location:
  • Phone: 360-736-0112
  • Fax:
Mailing address:
  • Phone: 407-529-4862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOC00001225
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: