Healthcare Provider Details

I. General information

NPI: 1083822027
Provider Name (Legal Business Name): SANDRA MARY COUGHLIN NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 04/11/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-57 HARRISON ST
JOHNSON CITY NY
13790-2107
US

IV. Provider business mailing address

33-57 HARRISON ST
JOHNSON CITY NY
13790-2107
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7009
  • Fax: 315-470-2923
Mailing address:
  • Phone: 315-470-7009
  • Fax: 315-470-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberF-350220-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF-350220
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: