Provider Demographics
NPI:1811475809
Name:COAKLEY, MINDY DAWN (AGNP)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:DAWN
Last Name:COAKLEY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:DAWN
Other - Last Name:BRAINARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2203A LANIER DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7738
Mailing Address - Country:US
Mailing Address - Phone:512-560-3367
Mailing Address - Fax:
Practice Address - Street 1:4100 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6056
Practice Address - Country:US
Practice Address - Phone:512-454-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX756883163WH0200X, 163WH1000X
TXAP144899363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WH1000XNursing Service ProvidersRegistered NurseHospice
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX388821601Medicaid