Basic Information
| Provider Information | |||||||||
| NPI: | 1427051549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COTTLE | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301-6 GREAT TEAYS BLVD | ||||||||
| Address2: | |||||||||
| City: | SCOTT DEPOT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047576999 | ||||||||
| FaxNumber: | 3047573252 | ||||||||
| Practice Location | |||||||||
| Address1: | 830 PENNSYLVANIA AVE | ||||||||
| Address2: | STE 402 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253023390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043435735 | ||||||||
| FaxNumber: | 3043435271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 11/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 081 | WV | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 000107768 | 01 | WV | MS BCBS | OTHER | 0160043000 | 05 | WV | MEDICAID | 1160043000 | 05 | WV | MEDICAID |