Healthcare Provider Details

I. General information

NPI: 1508802166
Provider Name (Legal Business Name): SERENA M COULOMBE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CLARK-HOLDER CLINIC, P.A. 303 SMITH STREET
LAGRANGE GA
30240
US

IV. Provider business mailing address

CLARK-HOLDER CLINIC, P.A. 303 SMITH STREET
LAGRANGE GA
30240
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-8831
  • Fax: 706-812-4091
Mailing address:
  • Phone: 706-882-8831
  • Fax: 706-812-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number51998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: