Provider Demographics
NPI:1508338161
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 1:130 WHITFORD RD
Mailing Address - Street 2:
Mailing Address - City:WESTTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10998-3524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 WHITFORD RD
Practice Address - Street 2:
Practice Address - City:WESTTOWN
Practice Address - State:NY
Practice Address - Zip Code:10998-3524
Practice Address - Country:US
Practice Address - Phone:845-590-1681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317928164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse