Provider Demographics
NPI:1679583991
Name:COOPER, NETRA (CFNP)
Entity Type:Individual
Prefix:
First Name:NETRA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0607
Mailing Address - Country:US
Mailing Address - Phone:601-859-9888
Mailing Address - Fax:601-859-9004
Practice Address - Street 1:1171 HART ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4805
Practice Address - Country:US
Practice Address - Phone:601-859-9888
Practice Address - Fax:601-859-9004
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR681636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115982Medicaid
MS0115982Medicaid