Provider Demographics
NPI:1093800252
Name:COOPER-HORNE, ELISE ROSE (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:ROSE
Last Name:COOPER-HORNE
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473425 E 1127 RD
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948
Mailing Address - Country:US
Mailing Address - Phone:918-427-7525
Mailing Address - Fax:
Practice Address - Street 1:301 S. JT STITES
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955
Practice Address - Country:US
Practice Address - Phone:918-775-9150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR551133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered