Provider Demographics
NPI:1689951402
Name:SMITH, DONNA (COTA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:SMITH
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 1:4635 RAGGEDY POINT RD
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7843
Mailing Address - Country:US
Mailing Address - Phone:904-269-3050
Mailing Address - Fax:
Practice Address - Street 1:8563 ARGYLE BUSINESS LOOP
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32244-6668
Practice Address - Country:US
Practice Address - Phone:904-375-0830
Practice Address - Fax:877-811-4031
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11958261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTA11958OtherFLORIDA DEPT. OF HEALTH