Provider Demographics
NPI:1154846707
Name:COOPER, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3301 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3713
Mailing Address - Country:US
Mailing Address - Phone:217-277-4090
Mailing Address - Fax:217-277-6778
Practice Address - Street 1:3301 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3713
Practice Address - Country:US
Practice Address - Phone:217-277-4090
Practice Address - Fax:217-277-6778
Is Sole Proprietor?:No
Enumeration Date:2017-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC280593367500000X
IL209024241367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered