Provider Demographics
NPI:1346915907
Name:COOPER, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:2059 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3067
Mailing Address - Country:US
Mailing Address - Phone:706-738-2996
Mailing Address - Fax:
Practice Address - Street 1:4825 JASMINE WAY
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-5874
Practice Address - Country:US
Practice Address - Phone:706-836-0979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator