Provider Demographics
NPI:1760241525
Name:COOPMAN, BROOK ANN (NP)
Entity Type:Individual
Prefix:
First Name:BROOK
Middle Name:ANN
Last Name:COOPMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BROOK
Other - Middle Name:ANN
Other - Last Name:LEISNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-834-4117
Practice Address - Street 1:620 SMITH AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-1080
Practice Address - Country:US
Practice Address - Phone:920-834-4110
Practice Address - Fax:920-834-4117
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15139-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100272586Medicaid