Healthcare Provider Details

I. General information

NPI: 1104984335
Provider Name (Legal Business Name): BERTULIE COICOU ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 SOUTHWINDS DR
LANTANA FL
33462-1459
US

IV. Provider business mailing address

1250 SOUTHWINDS DR
LANTANA FL
33462-1459
US

V. Phone/Fax

Practice location:
  • Phone: 561-547-6800
  • Fax: 561-837-5332
Mailing address:
  • Phone: 561-547-6800
  • Fax: 561-837-5332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 3027862
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: