Provider Demographics
NPI:1205322021
Name:COOPER, MIKYLA NAN (MAT, LAT, ATC)
Entity type:Individual
Prefix:MS
First Name:MIKYLA
Middle Name:NAN
Last Name:COOPER
Suffix:
Gender:F
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14157 SALMON DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0068
Mailing Address - Country:US
Mailing Address - Phone:405-708-8369
Mailing Address - Fax:
Practice Address - Street 1:4501 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-1160
Practice Address - Country:US
Practice Address - Phone:405-708-8369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AT75842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer