Provider Demographics
NPI:1568837276
Name:KOULABOUD, SEAN (APRN)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:KOULABOUD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:
Other - Last Name:KOULABOUD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:1600 CREEKSIDE DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-3447
Mailing Address - Country:US
Mailing Address - Phone:169-832-6639
Mailing Address - Fax:169-830-6029
Practice Address - Street 1:1600 CREEKSIDE DR STE 2100
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3447
Practice Address - Country:US
Practice Address - Phone:169-832-6639
Practice Address - Fax:169-830-6029
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSAPRN-53-76899363L00000X
KS53-76899363LF0000X
CA95004148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSAPRN-53-76899OtherKANSAS NURSING LICENSE
CA95004148OtherCALIFORNIA NURSING LICENSE