Provider Demographics
NPI:1205411600
Name:COOPER, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:8190 COUNTY ROUTE 70
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:NY
Mailing Address - Zip Code:14809-9549
Mailing Address - Country:US
Mailing Address - Phone:607-794-7892
Mailing Address - Fax:
Practice Address - Street 1:7309 SENECA RD N
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9691
Practice Address - Country:US
Practice Address - Phone:607-282-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322939-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161039939OtherALL OTHER INSURANCE
NY161039939Medicaid