Provider Demographics
NPI:1881653798
Name:COULTER, BEVERLY
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:
Last Name:COULTER
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 1:5616 BRAINERD RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-5374
Mailing Address - Country:US
Mailing Address - Phone:423-265-3561
Mailing Address - Fax:423-265-1364
Practice Address - Street 1:5616 BRAINERD RD
Practice Address - Street 2:SUITE 208
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5374
Practice Address - Country:US
Practice Address - Phone:423-265-3561
Practice Address - Fax:423-265-1364
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113998163W00000X
TN7575363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3344881Medicare ID - Type Unspecified