Provider Demographics
NPI:1194031880
Name:COULTER, MICHAEL (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COULTER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13453 N MAIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-2773
Mailing Address - Country:US
Mailing Address - Phone:904-773-4390
Mailing Address - Fax:941-621-7089
Practice Address - Street 1:13453 N MAIN ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-2773
Practice Address - Country:US
Practice Address - Phone:904-773-4390
Practice Address - Fax:941-621-7089
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9262190363L00000X
FLAPRN9262190363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002592800Medicaid
FLSF935OtherMEDICARE
FL116312100Medicaid