Provider Demographics
NPI:1689942153
Name:FRAZIER, KEWANNA D (OTA)
Entity Type:Individual
Prefix:
First Name:KEWANNA
Middle Name:D
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 ROUTE 202
Mailing Address - Street 2:APT. 3H
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2606
Mailing Address - Country:US
Mailing Address - Phone:302-465-2034
Mailing Address - Fax:
Practice Address - Street 1:229 ROUTE 202
Practice Address - Street 2:APT. 3H
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970
Practice Address - Country:US
Practice Address - Phone:302-465-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007987-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant