Provider Demographics
NPI:1679452858
Name:COUGHRAN, KAITLYN NICOLE
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:COUGHRAN
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 1:2235 MERCURY WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5472
Mailing Address - Country:US
Mailing Address - Phone:925-667-5878
Mailing Address - Fax:
Practice Address - Street 1:2235 MERCURY WAY STE 107
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5472
Practice Address - Country:US
Practice Address - Phone:707-571-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-01
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner