Provider Demographics
NPI:1497998371
Name:PRINCE, CORALIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:CORALIE
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 EMERSON DR SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-4972
Mailing Address - Country:US
Mailing Address - Phone:321-299-7687
Mailing Address - Fax:
Practice Address - Street 1:2440 EMERSON DR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-4972
Practice Address - Country:US
Practice Address - Phone:321-299-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11411177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL142640100Medicaid