Provider Demographics
NPI:1649308750
Name:COOPER, MARIE JEANETTE (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:JEANETTE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:MARIE
Other - Middle Name:JEANETTE
Other - Last Name:TAUTFEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:12150 KENT AVE
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544
Mailing Address - Country:US
Mailing Address - Phone:208-476-5064
Mailing Address - Fax:
Practice Address - Street 1:111 BEVER GRADE
Practice Address - Street 2:
Practice Address - City:LAPWAI
Practice Address - State:ID
Practice Address - Zip Code:83540
Practice Address - Country:US
Practice Address - Phone:208-843-7221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPN13277164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse