Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 3007739 | KY |
NPI | 1699029462 |
---|---|
Provider Name | Crystal Ann Cooper |
First Address | Corbin, KY 40702-1325 |
Second Address | Gray, KY 40734-4536 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2012 |
Last Update Date | 16/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100225480 | (05) | KY |
K068550 | MEDICARE PTAN (01) | KY |