Provider Demographics
NPI:1821769993
Name:COULSEY, MANDY CAROL (PA)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:CAROL
Last Name:COULSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5240 DENNING AVE
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-5100
Mailing Address - Country:US
Mailing Address - Phone:208-243-3612
Mailing Address - Fax:
Practice Address - Street 1:1649 LUCERNE ST
Practice Address - Street 2:
Practice Address - City:MINDEN
Practice Address - State:NV
Practice Address - Zip Code:89423-4369
Practice Address - Country:US
Practice Address - Phone:775-782-1603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical