Provider Demographics
NPI:1013507227
Name:COOPER, AMY DAWN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:DAWN
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4874 CABIN CREEK ROAD
Mailing Address - Street 2:4874 CABIN CREEK ROAD
Mailing Address - City:MIAMI
Mailing Address - State:WV
Mailing Address - Zip Code:25134-0277
Mailing Address - Country:US
Mailing Address - Phone:681-799-0334
Mailing Address - Fax:
Practice Address - Street 1:4874 CABIN CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25134
Practice Address - Country:US
Practice Address - Phone:681-799-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant