Provider Demographics
NPI:1356425789
Name:COOPER, BRENDA CAROLYN (RNC,ARNP)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:CAROLYN
Last Name:COOPER
Suffix:
Gender:F
Credentials:RNC,ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-1835
Mailing Address - Country:US
Mailing Address - Phone:270-442-5842
Mailing Address - Fax:270-442-9948
Practice Address - Street 1:1101 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-1835
Practice Address - Country:US
Practice Address - Phone:270-442-5842
Practice Address - Fax:270-442-9948
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1046053363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78015633Medicaid