Provider Demographics
NPI:1699067488
Name:COASTAL SOUTHEASTERN FAMILY PRACTICE, PLLC
Entity type:Organization
Organization Name:COASTAL SOUTHEASTERN FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-521-0099
Mailing Address - Street 1:205 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8768
Mailing Address - Country:US
Mailing Address - Phone:910-521-0099
Mailing Address - Fax:910-521-0088
Practice Address - Street 1:205 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-8768
Practice Address - Country:US
Practice Address - Phone:910-521-0099
Practice Address - Fax:910-521-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty