Provider Demographics
NPI:1437131562
Name:COUILLARD, MARY G (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:G
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 SPRING HILL DR
Mailing Address - Street 2:
Mailing Address - City:EDDYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42038-8759
Mailing Address - Country:US
Mailing Address - Phone:270-388-9284
Mailing Address - Fax:
Practice Address - Street 1:627 SPRING HILL DR
Practice Address - Street 2:
Practice Address - City:EDDYVILLE
Practice Address - State:KY
Practice Address - Zip Code:42038-8759
Practice Address - Country:US
Practice Address - Phone:270-388-9284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000382438OtherANTHEM 12 DIGIT UPIN
KY000000382438OtherANTHEM 12 DIGIT UPIN
KYNP00105Medicare ID - Type Unspecified