Provider Demographics
NPI:1609226273
Name:COOPER, CARLA (DPT, GCS)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:DPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 ZIRCON LN
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7233
Mailing Address - Country:US
Mailing Address - Phone:252-813-8582
Mailing Address - Fax:
Practice Address - Street 1:1210 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:NC
Practice Address - Zip Code:27856-1817
Practice Address - Country:US
Practice Address - Phone:252-462-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39275314000000X
NC11020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility