Provider Demographics
NPI:1497361240
Name:COOPER, OLLIE MARIE
Entity Type:Individual
Prefix:
First Name:OLLIE
Middle Name:MARIE
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:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH
Mailing Address - State:WV
Mailing Address - Zip Code:25132-0111
Mailing Address - Country:US
Mailing Address - Phone:304-542-9352
Mailing Address - Fax:
Practice Address - Street 1:85 MOUNT LEWIS CEMETARY RD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:WV
Practice Address - Zip Code:25039-7725
Practice Address - Country:US
Practice Address - Phone:304-542-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-17
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant