Provider Demographics
NPI:1346022456
Name:COOPER, CARLY JOY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JOY
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JOY
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-9361
Mailing Address - Country:US
Mailing Address - Phone:814-944-4722
Mailing Address - Fax:814-266-2880
Practice Address - Street 1:2900 PLANK RD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-9361
Practice Address - Country:US
Practice Address - Phone:814-944-4722
Practice Address - Fax:814-266-2880
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN627642163W00000X
PASP029281363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse