Provider Demographics
NPI:1558946343
Name:KNUTH, REBECCA ANN (COTA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KNUTH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22424 S ELLSWORTH LOOP RD UNIT 464
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-7070
Mailing Address - Country:US
Mailing Address - Phone:480-757-2253
Mailing Address - Fax:
Practice Address - Street 1:22424 S ELLSWORTH LOOP RD UNIT 464
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-7070
Practice Address - Country:US
Practice Address - Phone:480-757-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP6283207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology