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General NPI Number Information
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NPI Number | 1417476896
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Entity Type | Individual
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Provider Name | LAUREN PARK COTA/L
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Gender | Female
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Dates
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Enumeration Date | 09/17/2017
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Last Update Date | 09/17/2017
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Provider Practice Location Address
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Address Line | 235 9TH AVE N
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-7142
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Country | US
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Telephone | 904-249-8893
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Fax |
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Provider Business Mailing Address
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Address Line | 2989 MIKRIS DR E
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City | JACKSONVILLE
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State | FL
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Zip | 32225-7624
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Country | US
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Telephone | 217-620-8355
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OTA16115
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License Number State | FL
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