Basic Information
Provider Information | |||||||||
NPI: | 1457654964 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COULTES | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JUILLANTI | ||||||||
OtherFirstName: | NICOLE | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 191 | ||||||||
Address2: |   | ||||||||
City: | ROCKLAND | ||||||||
State: | DE | ||||||||
PostalCode: | 197230191 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026514000 | ||||||||
FaxNumber: | 3026514945 | ||||||||
Practice Location | |||||||||
Address1: | 701 E MARSHALL ST | ||||||||
Address2: |   | ||||||||
City: | WEST CHESTER | ||||||||
State: | PA | ||||||||
PostalCode: | 193804412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104315472 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/06/2010 | ||||||||
LastUpdateDate: | 06/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | L60A00611 | DE | N |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   | 367H00000X | L10038271 | DE | N |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   | 367500000X | RN556715 | PA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.