Provider Demographics
NPI:1255477394
Name:COOPER, JOHANNA KARIN (FNP)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:KARIN
Last Name:COOPER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0467
Mailing Address - Country:US
Mailing Address - Phone:505-782-4431
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 301 NORTH & B AVENUE
Practice Address - Street 2:ZUNI HOSPITAL
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327
Practice Address - Country:US
Practice Address - Phone:505-782-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236137363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65456327Medicaid
NM65456327Medicaid