Provider Demographics
NPI:1629129762
Name:COOMES, THERESA A (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:A
Last Name:COOMES
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 1:600 KINGS ESTATE RD
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5336
Mailing Address - Country:US
Mailing Address - Phone:904-806-5273
Mailing Address - Fax:
Practice Address - Street 1:161A MARINE ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5154
Practice Address - Country:US
Practice Address - Phone:904-806-5273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL715622363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303938100Medicaid