Provider Demographics
NPI:1992164669
Name:COUCOULES, KAITLYN ANN
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ANN
Last Name:COUCOULES
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 1:23000 MOAKLEY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-5555
Mailing Address - Fax:301-475-5914
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-5555
Practice Address - Fax:301-475-5914
Is Sole Proprietor?:No
Enumeration Date:2016-02-23
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06063363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant