Provider Demographics
NPI:1528328051
Name:COAKLEY, KATHLEEN M (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:COAKLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:
Practice Address - Street 1:200 BOWMAN DR STE E355
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9643
Practice Address - Country:US
Practice Address - Phone:856-247-7210
Practice Address - Fax:856-247-7511
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB10389100208600000X
NC2016-01565208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC2846Medicaid
NC1528328051Medicaid
NJ0642932Medicaid