Provider Demographics
NPI:1285834697
Name:COOPER, SHANEEYA KYEA (RN)
Entity Type:Individual
Prefix:MISS
First Name:SHANEEYA
Middle Name:KYEA
Last Name:COOPER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 POND VIEW HTS
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-1308
Mailing Address - Country:US
Mailing Address - Phone:585-820-1912
Mailing Address - Fax:
Practice Address - Street 1:142 POND VIEW HTS
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-1308
Practice Address - Country:US
Practice Address - Phone:585-820-1912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2850441164W00000X
NY22655029163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02816131Medicaid