Provider Demographics
NPI:1508014077
Name:COOLEY, BETTY JO (LPN)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:JO
Last Name:COOLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S HERMON RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7311
Mailing Address - Country:US
Mailing Address - Phone:907-631-3971
Mailing Address - Fax:907-631-4085
Practice Address - Street 1:801 S HERMON RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7311
Practice Address - Country:US
Practice Address - Phone:907-631-3971
Practice Address - Fax:907-631-4085
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100689320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities