Healthcare Provider Details

I. General information

NPI: 1326876780
Provider Name (Legal Business Name): MRS. KANSAS REBECCAMARIE COUGHLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 MCNUTT RD
SUNLAND PARK NM
88008-9621
US

IV. Provider business mailing address

13183 EMERALD ISLE ST
EL PASO TX
79928-5343
US

V. Phone/Fax

Practice location:
  • Phone: 575-882-6101
  • Fax:
Mailing address:
  • Phone: 469-424-7711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number1150952
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: