Provider Demographics
NPI:1295320075
Name:COOPER, ANNA MARYALICE (CRNP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARYALICE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARYALICE
Other - Last Name:NEWCOMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:570-326-8723
Mailing Address - Fax:570-326-8922
Practice Address - Street 1:700 HIGH ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3100
Practice Address - Country:US
Practice Address - Phone:570-321-3454
Practice Address - Fax:570-321-3455
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023296363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner