1912344490 NPI number — MRS. KIMBERLY JOY MCCOLLOM COTA

Table of content: MRS. KIMBERLY JOY MCCOLLOM COTA (NPI 1912344490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912344490 NPI number — MRS. KIMBERLY JOY MCCOLLOM COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCOLLOM
Provider First Name:
KIMBERLY
Provider Middle Name:
JOY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOANE
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
JOY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912344490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5404 PRESTON FALL CITY RD SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALL CITY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98024-9628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-435-9292
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5404 PRESTON FALL CITY RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL CITY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98024-9628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-435-9292
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2013

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: 224Z00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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