Provider Demographics
NPI:1740303676
Name:COOPER, PORTIA ANN (LPN)
Entity type:Individual
Prefix:MS
First Name:PORTIA
Middle Name:ANN
Last Name:COOPER
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 1:7211 BROOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5279
Mailing Address - Country:US
Mailing Address - Phone:614-501-0851
Mailing Address - Fax:614-501-0851
Practice Address - Street 1:7211 BROOKE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-5279
Practice Address - Country:US
Practice Address - Phone:614-501-0851
Practice Address - Fax:614-501-0851
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN087534164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse