Provider Demographics
NPI:1205006871
Name:COOPER, DANA LEE (FNP)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:LEE
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:413 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:MO
Mailing Address - Zip Code:63933-1523
Mailing Address - Country:US
Mailing Address - Phone:573-246-2582
Mailing Address - Fax:573-246-3246
Practice Address - Street 1:413 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:MO
Practice Address - Zip Code:63933-1523
Practice Address - Country:US
Practice Address - Phone:573-246-2582
Practice Address - Fax:573-246-3246
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO093670363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000010626OtherGROUP PROVIDER TRANSACTION ACCESS NUMBER
MO428416705Medicaid
MO838710626OtherPROVIDER TRANSACTION ACCESS NUMBER
MO000010626OtherGROUP PROVIDER TRANSACTION ACCESS NUMBER
MOOTH00Medicare UPIN