Provider Demographics
NPI:1063445799
Name:COTHERMAN, PATRICIA ANN (RD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:COTHERMAN
Suffix:
Gender:F
Credentials:RD
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 6710
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-6710
Mailing Address - Country:US
Mailing Address - Phone:707-994-6486
Mailing Address - Fax:707-994-8731
Practice Address - Street 1:15630 18TH AVE
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422
Practice Address - Country:US
Practice Address - Phone:707-994-6486
Practice Address - Fax:707-994-8731
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHR317017133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered