Provider Demographics
NPI:1255129110
Name:COOPER, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:COOPER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 E CLARK ST APT 420
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-2307
Mailing Address - Country:US
Mailing Address - Phone:605-641-7117
Mailing Address - Fax:
Practice Address - Street 1:414 E CLARK ST APT 420
Practice Address - Street 2:
Practice Address - City:VERMILLION
Practice Address - State:SD
Practice Address - Zip Code:57069-2307
Practice Address - Country:US
Practice Address - Phone:605-641-7117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program