Provider Demographics
NPI:1629740642
Name:COOPER, CHARLOTTE ANNE
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANNE
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 1:175 SPALDING CREEK CT
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-1142
Mailing Address - Country:US
Mailing Address - Phone:770-789-3696
Mailing Address - Fax:
Practice Address - Street 1:745 POPLAR RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1618
Practice Address - Country:US
Practice Address - Phone:770-400-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN254690163WN0002X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A