Provider Demographics
NPI:1558871095
Name:COOPER, MICHELLE MAKEBA (FNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MAKEBA
Last Name:COOPER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 RANDALL ROAD
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056
Mailing Address - Country:US
Mailing Address - Phone:413-858-0853
Mailing Address - Fax:413-858-0772
Practice Address - Street 1:627 RANDALL ROAD
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056
Practice Address - Country:US
Practice Address - Phone:413-858-0853
Practice Address - Fax:413-858-0772
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266134363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse