=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104150622
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIERAH DAWN WONSER COTA/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2009
-----------------------------------------------------
Last Update Date | 09/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 S 18TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-742-3728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 S 10TH ST APT. D
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-4695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-262-6143
-----------------------------------------------------
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 | COTA 737
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------