Provider Demographics
NPI:1750316881
Name:COOPER, KIM (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5903 RIDGEWOOD RD STE 310
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3702
Mailing Address - Country:US
Mailing Address - Phone:601-899-3310
Mailing Address - Fax:
Practice Address - Street 1:5903 RIDGEWOOD RD STE 310
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3702
Practice Address - Country:US
Practice Address - Phone:601-899-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR639893363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126107Medicaid
MS202011213AOtherBLUE CROSS
MSP66537Medicare UPIN
MS500001811Medicare ID - Type Unspecified