Provider Demographics
NPI:1801486527
Name:COOPER, KATHLEEN NICOLE
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NICOLE
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 1:1036 RONALD ST
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1634
Mailing Address - Country:US
Mailing Address - Phone:937-723-1902
Mailing Address - Fax:
Practice Address - Street 1:1036 RONALD ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1634
Practice Address - Country:US
Practice Address - Phone:937-723-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03839653747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant