Healthcare Provider Details

I. General information

NPI: 1790711828
Provider Name (Legal Business Name): THERESA E COYNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1569
US

IV. Provider business mailing address

124 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1569
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-6722
  • Fax: 765-463-0905
Mailing address:
  • Phone: 765-463-6722
  • Fax: 765-463-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001017A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: