Healthcare Provider Details

I. General information

NPI: 1962683623
Provider Name (Legal Business Name): COAST NURSE PRACTITIONERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13300 RS KIMBALL RD
VANCLEAVE MS
39565-7235
US

IV. Provider business mailing address

PO BOX 5386
VANCLEAVE MS
39565-5386
US

V. Phone/Fax

Practice location:
  • Phone: 228-826-4600
  • Fax: 228-392-8393
Mailing address:
  • Phone: 228-826-4600
  • Fax: 228-392-8393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR851501
License Number StateMS

VIII. Authorized Official

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