Provider Demographics
NPI:1437106762
Name:COOPER, M. ELIZABETH (APN)
Entity Type:Individual
Prefix:MS
First Name:M. ELIZABETH
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 FRANKLIN AVE
Mailing Address - Street 2:#4800
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3551
Mailing Address - Country:US
Mailing Address - Phone:309-454-5900
Mailing Address - Fax:309-454-2820
Practice Address - Street 1:1302 FRANKLIN AVE
Practice Address - Street 2:#4800
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3551
Practice Address - Country:US
Practice Address - Phone:309-454-5900
Practice Address - Fax:309-454-2820
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-005282363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05732097OtherBCBS
IL105322OtherHEALTH ALLIANCE
IL906770OtherMEDICARE GROUP
IL05732097OtherBCBS
IL906770OtherMEDICARE GROUP
ILP00299796Medicare ID - Type UnspecifiedRR MEDICARE