Provider Demographics
NPI:1164244810
Name:TRITON, PHAEDRA (COTA)
Entity type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:
Last Name:TRITON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:PHAEDRA
Other - Middle Name:
Other - Last Name:STARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2509 NORTH WATERLEAF DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092
Mailing Address - Country:US
Mailing Address - Phone:619-366-0228
Mailing Address - Fax:
Practice Address - Street 1:2103 GILMORE STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-906-3878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant