Basic Information
| Provider Information | |||||||||
| NPI: | 1417908286 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COGHLAN | ||||||||
| FirstName: | CLODAGH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 368 DORSET ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SOUTH BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054036236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028601441 | ||||||||
| FaxNumber: | 8028604646 | ||||||||
| Practice Location | |||||||||
| Address1: | 368 DORSET ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SOUTH BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054036236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028601441 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 01/13/2010 | ||||||||
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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 | 1010018859 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ONP1034 | 05 | VT | MEDICAID | 500016102 | 01 | VT | RAIL ROAD MEDICARE | OTHER |