Provider Demographics
NPI:1487629663
Name:COULTER, KATHLEEN (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:COULTER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 SPRINGHOUSE LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5347
Mailing Address - Country:US
Mailing Address - Phone:610-721-0277
Mailing Address - Fax:
Practice Address - Street 1:340 N MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5597
Practice Address - Country:US
Practice Address - Phone:610-891-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025692363LP0808X
PASP006850C363LA2200X
PASP006851H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA069804HK1Medicare ID - Type Unspecified
P89434Medicare UPIN