Provider Demographics
NPI:1548695810
Name:COOPER, TRACY
Entity type:Individual
Prefix:
First Name:TRACY
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:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:UNALAKLEET
Mailing Address - State:AK
Mailing Address - Zip Code:99684-0270
Mailing Address - Country:US
Mailing Address - Phone:907-624-3622
Mailing Address - Fax:907-624-3619
Practice Address - Street 1:270 MARTHA ANAGICK AARONS SUBDIVISION
Practice Address - Street 2:
Practice Address - City:UNALAKLEET
Practice Address - State:AK
Practice Address - Zip Code:99684-0270
Practice Address - Country:US
Practice Address - Phone:907-624-3622
Practice Address - Fax:907-624-3621
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101399310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility