Provider Demographics
NPI:1346728730
Name:COOPER, KRYSTA MYCHAL (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:MYCHAL
Last Name:COOPER
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 COTTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45335-1518
Mailing Address - Country:US
Mailing Address - Phone:937-675-2870
Mailing Address - Fax:937-675-2873
Practice Address - Street 1:4790 COTTONVILLE RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:OH
Practice Address - Zip Code:45335-1518
Practice Address - Country:US
Practice Address - Phone:937-675-2870
Practice Address - Fax:937-675-2873
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00024808207Q00000X
OHAPRN.CNP.023461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315026Medicaid