Provider Demographics
NPI:1649404252
Name:COOPER, DONNA MARIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:MARIE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:500 ARCADE AVE STE 400
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2487
Practice Address - Country:US
Practice Address - Phone:574-522-2284
Practice Address - Fax:574-522-3952
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002700A363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200977080Medicaid