Provider Demographics
NPI:1871262634
Name:COULOMBE, DANIE MOLY
Entity Type:Individual
Prefix:
First Name:DANIE
Middle Name:MOLY
Last Name:COULOMBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N ORANGE BLOSSOM TRL STE 205
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 N ORANGE BLOSSOM TRL STE 205
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-2307
Practice Address - Country:US
Practice Address - Phone:407-944-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010414163WG0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty