Provider Demographics
NPI:1902566151
Name:COLEMAN, MARIE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:COLEMAN
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 1:10430 COUNTRY BLF
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4413
Mailing Address - Country:US
Mailing Address - Phone:210-363-2215
Mailing Address - Fax:
Practice Address - Street 1:10430 COUNTRY BLF
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4413
Practice Address - Country:US
Practice Address - Phone:210-363-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1058102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily