Healthcare Provider Details

I. General information

NPI: 1851695720
Provider Name (Legal Business Name): COAST NURSE PRACTITIONERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13300 R.S. KIMBALL ROAD
VANCLEAVE MS
39565
US

IV. Provider business mailing address

P.O. BOX 5386
VANCLEAVE MS
39565
US

V. Phone/Fax

Practice location:
  • Phone: 228-826-4600
  • Fax: 228-826-4600
Mailing address:
  • Phone: 228-826-4600
  • Fax: 228-826-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateMS

VIII. Authorized Official

Name: JOHN M MARTIN
Title or Position: OWNER
Credential: NP
Phone: 228-826-4600