Provider Demographics
NPI:1255763314
Name:COUGHLIN, NICOLE CATHERINE
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:CATHERINE
Last Name:COUGHLIN
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 1:28 BREEZEWAY CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-8494
Mailing Address - Country:US
Mailing Address - Phone:631-766-2743
Mailing Address - Fax:
Practice Address - Street 1:28 BREEZEWAY CT
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-8494
Practice Address - Country:US
Practice Address - Phone:631-766-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-31
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY723405131252Y00000X
NY723406131252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency