Provider Demographics
NPI:1770544686
Name:COOPER, DIANNE PATRICIA
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:PATRICIA
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 1:6079 NE 9TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50313-1531
Mailing Address - Country:US
Mailing Address - Phone:515-778-4982
Mailing Address - Fax:515-289-4051
Practice Address - Street 1:6079 NE 9TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50313-1531
Practice Address - Country:US
Practice Address - Phone:515-778-4982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-079349367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered