Provider Demographics
NPI:1649268079
Name:COFFEY, JEAN S (PHD, APRN , CPNP)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:S
Last Name:COFFEY
Suffix:
Gender:F
Credentials:PHD, APRN , CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:PEDIATRICS
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-653-9667
Mailing Address - Fax:603-650-0910
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:PEDIATRICS
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-653-9667
Practice Address - Fax:603-650-0910
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT101-0012248363LP0200X
NH025532-23363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010958Medicaid
VTCO NP4883Medicare PIN