Provider Demographics
NPI:1518311968
Name:COOPER, KAYLA
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:
Other - Last Name:SABOTCHICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:354 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:ELYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17824-9753
Mailing Address - Country:US
Mailing Address - Phone:570-850-5780
Mailing Address - Fax:
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20727367500000X
PARN614980367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032778540001Medicaid