Provider Demographics
NPI:1437369469
Name:COKE, CARILYN FAY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CARILYN
Middle Name:FAY
Last Name:COKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W KING ST
Mailing Address - Street 2:
Mailing Address - City:COULTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62237-1529
Mailing Address - Country:US
Mailing Address - Phone:618-758-1188
Mailing Address - Fax:
Practice Address - Street 1:900 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1230
Practice Address - Country:US
Practice Address - Phone:618-542-2146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant