Provider Demographics
NPI:1679658082
Name:WORTHCOTA, CONNIE MARIE (COTA)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:MARIE
Last Name:WORTHCOTA
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 1:112 POWER LANE
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85939-0000
Mailing Address - Country:US
Mailing Address - Phone:928-536-7526
Mailing Address - Fax:
Practice Address - Street 1:682 W SCHOOL BUS LN
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5262
Practice Address - Country:US
Practice Address - Phone:928-536-4156
Practice Address - Fax:928-536-4156
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2253OtherCOTA