Healthcare Provider Details

I. General information

NPI: 1407105315
Provider Name (Legal Business Name): KRISTA NICOLE CRONK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 09/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 S. 102ND STREET STE 340
MILWAUKEE WI
53227-2141
US

IV. Provider business mailing address

908 LINCOLN AVE
AMERY WI
54001
US

V. Phone/Fax

Practice location:
  • Phone: 800-776-7016
  • Fax:
Mailing address:
  • Phone: 715-220-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4939-27
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: