Provider Demographics
NPI:1760611230
Name:COOPER, CRYSTAL LEE (LPN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 AMOY GANGES RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9769
Mailing Address - Country:US
Mailing Address - Phone:419-610-1742
Mailing Address - Fax:
Practice Address - Street 1:2908 AMOY GANGES RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9769
Practice Address - Country:US
Practice Address - Phone:419-610-1742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN114000164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse