Provider Demographics
NPI:1063015550
Name:COOPER, SHARI DENISE
Entity Type:Individual
Prefix:
First Name:SHARI
Middle Name:DENISE
Last Name:COOPER
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 1:4583 KALIDA AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-5768
Mailing Address - Country:US
Mailing Address - Phone:937-286-8305
Mailing Address - Fax:
Practice Address - Street 1:4583 KALIDA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-5768
Practice Address - Country:US
Practice Address - Phone:937-286-8305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3077960Other3076960
OH3076960Medicaid