Provider Demographics
NPI:1629661210
Name:COOPER, HEIDI JO (PNP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JO
Last Name:COOPER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:JO
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:700 W. IRONWOOD DRIVE
Mailing Address - Street 2:SUITE 155
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4462
Mailing Address - Country:US
Mailing Address - Phone:208-667-0585
Mailing Address - Fax:208-625-2075
Practice Address - Street 1:217 S HANDY ST
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7283
Practice Address - Country:US
Practice Address - Phone:208-661-5991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP74551363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1629661210Medicaid