Provider Demographics
NPI:1538181839
Name:KOOPERMAN, DENISE ELIZABETH (NP, MSN, CS)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:ELIZABETH
Last Name:KOOPERMAN
Suffix:
Gender:F
Credentials:NP, MSN, CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9182
Mailing Address - Country:US
Mailing Address - Phone:607-387-3128
Mailing Address - Fax:607-272-3547
Practice Address - Street 1:313 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4205
Practice Address - Country:US
Practice Address - Phone:607-272-1014
Practice Address - Fax:607-272-3547
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400114-1163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02509924Medicaid
NYR56004Medicare UPIN
NY55354BMedicare ID - Type Unspecified