Provider Demographics
NPI:1902904394
Name:COOPER, LORI J (APRN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:COOPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2149 E WARNER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3495
Mailing Address - Country:US
Mailing Address - Phone:480-610-6100
Mailing Address - Fax:
Practice Address - Street 1:2141 E WARNER RD
Practice Address - Street 2:STE. 101
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3493
Practice Address - Country:US
Practice Address - Phone:480-969-8714
Practice Address - Fax:480-464-0189
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAPO254363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ396540Medicaid
AZ396540Medicaid
AZ112353Medicare PIN