=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003222530
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FANNY BRISTOL COTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2014
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 E TEXAS BLVD
-----------------------------------------------------
City | DALHART
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79022-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-244-0015
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 18
-----------------------------------------------------
City | GRAND ISLAND
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68802-0018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-468-0416
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 215641
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 933
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------