Provider Demographics
NPI:1427655620
Name:COTNER, MIKI CHRISTINE (MAT-14159)
Entity type:Individual
Prefix:
First Name:MIKI
Middle Name:CHRISTINE
Last Name:COTNER
Suffix:
Gender:F
Credentials:MAT-14159
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35476 CAMINO CAPISTRANO APT A
Mailing Address - Street 2:
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1852
Mailing Address - Country:US
Mailing Address - Phone:808-492-9920
Mailing Address - Fax:
Practice Address - Street 1:35476 CAMINO CAPISTRANO APT A
Practice Address - Street 2:
Practice Address - City:CAPISTRANO BEACH
Practice Address - State:CA
Practice Address - Zip Code:92624-1852
Practice Address - Country:US
Practice Address - Phone:808-492-9920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMAT-14159225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist