Provider Demographics
NPI:1104184878
Name:COULTER, KATHERINE JEAN (DNP,APN,FNP-BC,MSN)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:JEAN
Last Name:COULTER
Suffix:
Gender:F
Credentials:DNP,APN,FNP-BC,MSN
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:JEAN
Other - Last Name:PERIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP,APN,FNP-BC,MSN
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:380 E IL ROUTE 38
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068-9694
Practice Address - Country:US
Practice Address - Phone:779-696-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009522363L00000X
IL277-000567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL5966012OtherMEDICARE PTAN (INDIVIDUAL)