Provider Demographics
NPI:1053088575
Name:COULTAS, WHITNEY RACHELLE
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:RACHELLE
Last Name:COULTAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 ROXY ANN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8065
Mailing Address - Country:US
Mailing Address - Phone:541-261-7123
Mailing Address - Fax:
Practice Address - Street 1:3265 HILLCREST PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7657
Practice Address - Country:US
Practice Address - Phone:541-275-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201602008RN163W00000X
OR202111129NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500798345Medicaid