Healthcare Provider Details

I. General information

NPI: 1114572245
Provider Name (Legal Business Name): COASTAL ESTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W KNAPP AVE
EDGEWATER FL
32132-1555
US

IV. Provider business mailing address

109 W KNAPP AVE
EDGEWATER FL
32132-1555
US

V. Phone/Fax

Practice location:
  • Phone: 386-957-4100
  • Fax: 386-957-4104
Mailing address:
  • Phone: 386-957-4100
  • Fax: 386-957-4104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CARISSA PETERSON
Title or Position: OWNER/APRN
Credential: APRN
Phone: 386-957-4100