Provider Demographics
NPI:1548457880
Name:COOPER, SUSAN B
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
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 1:700 STATE ROUTE 551
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9699
Mailing Address - Country:US
Mailing Address - Phone:740-947-4684
Mailing Address - Fax:740-947-6538
Practice Address - Street 1:100 DAWN LN
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9138
Practice Address - Country:US
Practice Address - Phone:740-947-6306
Practice Address - Fax:740-947-6538
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager