Provider Demographics
NPI:1669615621
Name:COOPER, KRISTIN HERRNSTEIN
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:HERRNSTEIN
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 MIMOSA PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6230
Mailing Address - Country:US
Mailing Address - Phone:740-701-7456
Mailing Address - Fax:
Practice Address - Street 1:5800 MIMOSA PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6230
Practice Address - Country:US
Practice Address - Phone:740-701-7456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2521225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ0546Medicaid