Healthcare Provider Details

I. General information

NPI: 1679904932
Provider Name (Legal Business Name): CAROLYN COUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 SW 23RD TER APT 1502
GAINESVILLE FL
32608-2956
US

IV. Provider business mailing address

2930 SW 23RD TER APT 1502
GAINESVILLE FL
32608-2956
US

V. Phone/Fax

Practice location:
  • Phone: 239-634-0267
  • Fax:
Mailing address:
  • Phone: 239-634-0267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSI28768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: