Healthcare Provider Details

I. General information

NPI: 1205744455
Provider Name (Legal Business Name): SHANON LEIGH COULTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10703 MILWAUKEE AVE
LUBBOCK TX
79424-6153
US

IV. Provider business mailing address

10703 MILWAUKEE AVE
LUBBOCK TX
79424-6153
US

V. Phone/Fax

Practice location:
  • Phone: 806-777-1350
  • Fax:
Mailing address:
  • Phone: 806-777-1350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0121X
TaxonomyPlastic Surgery Registered Nurse
License Number647411
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: