=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083257604
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONETTA LOU COULTER APRN-CNS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2019
-----------------------------------------------------
Last Update Date | 10/27/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 W BROAD ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43222-1054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-272-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 566 E KELSO RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43202-2326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-268-7109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 364SA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Clinical Nurse Specialist
-----------------------------------------------------
License Number | APRNCNS019419
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------