Provider Demographics
NPI:1134862030
Name:COLEMAN, BERNICE
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:COLEMAN
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 1:405 ISAAC CIR APT D
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-9036
Mailing Address - Country:US
Mailing Address - Phone:972-880-7217
Mailing Address - Fax:214-440-2276
Practice Address - Street 1:405 ISAAC CIR APT D
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-9036
Practice Address - Country:US
Practice Address - Phone:972-880-7217
Practice Address - Fax:214-440-2276
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33676977172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver