Provider Demographics
NPI:1104984335
Name:COICOU, BERTULIE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:BERTULIE
Middle Name:
Last Name:COICOU
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 SOUTHWINDS DR
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1459
Mailing Address - Country:US
Mailing Address - Phone:561-547-6800
Mailing Address - Fax:561-837-5332
Practice Address - Street 1:1250 SOUTHWINDS DR
Practice Address - Street 2:
Practice Address - City:LANTANA
Practice Address - State:FL
Practice Address - Zip Code:33462-1459
Practice Address - Country:US
Practice Address - Phone:561-547-6800
Practice Address - Fax:561-837-5332
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3027862363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308136200Medicaid
12789472OtherCAQH #