Provider Demographics
NPI:1770601908
Name:COOPER, TAMARA KAY
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:KAY
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 1:2913 LUCAS PERRYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LUCAS
Mailing Address - State:OH
Mailing Address - Zip Code:44843-9514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:OH
Practice Address - Zip Code:44822-9675
Practice Address - Country:US
Practice Address - Phone:419-883-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 104476164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2377404Medicaid