Provider Demographics
NPI:1396114302
Name:KOTLAR, THERESA BROOKS (RN)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:BROOKS
Last Name:KOTLAR
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:MALION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:7174 COLONIAL PLACE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44268
Mailing Address - Country:US
Mailing Address - Phone:330-906-3331
Mailing Address - Fax:
Practice Address - Street 1:7174 COLONIAL PLACE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-906-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-20
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213262163WH0200X, 163W00000X
OHRN213262251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No251J00000XAgenciesNursing Care