Provider Demographics
NPI:1063080802
Name:COURSON, RACHEL ANNE
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANNE
Last Name:COURSON
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 1:695 W BAFFIN DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-5674
Mailing Address - Country:US
Mailing Address - Phone:480-708-8470
Mailing Address - Fax:
Practice Address - Street 1:17178 TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-2626
Practice Address - Country:US
Practice Address - Phone:941-625-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25971122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist