Provider Demographics
NPI:1881461663
Name:PURYEAR, KORTNEY NICOLE (COTA/L)
Entity type:Individual
Prefix:
First Name:KORTNEY
Middle Name:NICOLE
Last Name:PURYEAR
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 TANK RD
Mailing Address - Street 2:
Mailing Address - City:NELSON
Mailing Address - State:VA
Mailing Address - Zip Code:24580-2819
Mailing Address - Country:US
Mailing Address - Phone:434-738-7940
Mailing Address - Fax:
Practice Address - Street 1:1100 CONFROY DR STE 4
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-7163
Practice Address - Country:US
Practice Address - Phone:434-835-9007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002587224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant