Basic Information
| Provider Information | |||||||||
| NPI: | 1124322508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUGHLAN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827294 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666716774 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 501 S 54TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191431900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157489000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 02/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN290938L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | SP011208 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.