Provider Demographics
NPI:1427051549
Name:COTTLE, SANDRA L IV (CNM)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:L
Last Name:COTTLE
Suffix:IV
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301-6 GREAT TEAYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:304-757-6999
Mailing Address - Fax:304-757-3252
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:STE 402
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3390
Practice Address - Country:US
Practice Address - Phone:304-343-5735
Practice Address - Fax:304-343-5271
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV081176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV000107768OtherMS BCBS
WV0160043000Medicaid
WV1160043000Medicaid
WV0160043000Medicaid
WVNM00253Medicare PIN