Provider Demographics
NPI:1124322508
Name:COUGHLAN, DIANE MARIE (CRNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:COUGHLAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 CHICHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER CHICHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19061-3139
Mailing Address - Country:US
Mailing Address - Phone:610-484-4422
Mailing Address - Fax:
Practice Address - Street 1:4115 CHICHESTER AVE
Practice Address - Street 2:
Practice Address - City:UPPER CHICHESTER
Practice Address - State:PA
Practice Address - Zip Code:19061-3139
Practice Address - Country:US
Practice Address - Phone:610-484-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-29
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011208363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner