Provider Demographics
NPI:1083257604
Name:COULTER, BONETTA LOU (APRN-CNS)
Entity Type:Individual
Prefix:
First Name:BONETTA
Middle Name:LOU
Last Name:COULTER
Suffix:
Gender:F
Credentials:APRN-CNS
Other - Prefix:
Other - First Name:BONNIE
Other - Middle Name:L
Other - Last Name:COULTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:566 E KELSO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-2326
Mailing Address - Country:US
Mailing Address - Phone:614-268-7109
Mailing Address - Fax:
Practice Address - Street 1:1601 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1054
Practice Address - Country:US
Practice Address - Phone:614-272-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-27
Last Update Date:2019-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNS019419364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health