1215256714 NPI number — MISS PRISCILLA R GRAY COTA/L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215256714 NPI number — MISS PRISCILLA R GRAY COTA/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAY
Provider First Name:
PRISCILLA
Provider Middle Name:
R
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
COTA/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215256714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2055 FAIRWAYS CT NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30144-2093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-903-2845
Provider Business Mailing Address Fax Number:
770-420-3341

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 TOWER RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-6947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-422-8913
Provider Business Practice Location Address Fax Number:
770-420-3341
Provider Enumeration Date:
05/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XG0600X , with the licence number:  000054OTA , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)