Provider Demographics
NPI:1184173973
Name:HOOPER, MICSHANNA (LVN)
Entity type:Individual
Prefix:
First Name:MICSHANNA
Middle Name:
Last Name:HOOPER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 BARDIN RD
Mailing Address - Street 2:418
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052
Mailing Address - Country:US
Mailing Address - Phone:682-300-7616
Mailing Address - Fax:
Practice Address - Street 1:3303 BARDIN RD
Practice Address - Street 2:418
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052
Practice Address - Country:US
Practice Address - Phone:682-300-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210438164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101010Medicaid