Provider Demographics
NPI:1124730759
Name:EASTHAM, CORI PAIGE
Entity type:Individual
Prefix:
First Name:CORI
Middle Name:PAIGE
Last Name:EASTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:KY
Mailing Address - Zip Code:42459-0032
Mailing Address - Country:US
Mailing Address - Phone:270-952-3043
Mailing Address - Fax:
Practice Address - Street 1:2480 US HIGHWAY 41 N STE 80
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2300
Practice Address - Country:US
Practice Address - Phone:270-823-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163952224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant