Provider Demographics
NPI:1144949405
Name:COOPER, CARLY
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
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 1:1660 FEEHANVILLE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-6036
Mailing Address - Country:US
Mailing Address - Phone:847-823-3185
Mailing Address - Fax:
Practice Address - Street 1:1660 FEEHANVILLE DR STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-6036
Practice Address - Country:US
Practice Address - Phone:847-823-3185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.010051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant