Healthcare Provider Details

I. General information

NPI: 1487629663
Provider Name (Legal Business Name): KATHLEEN COULTER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 N MIDDLETOWN RD
MEDIA PA
19063-5597
US

IV. Provider business mailing address

248 SPRINGHOUSE LN
MEDIA PA
19063-5347
US

V. Phone/Fax

Practice location:
  • Phone: 610-891-5600
  • Fax:
Mailing address:
  • Phone: 610-721-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP006850C
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberSP006851H
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP025692
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: