Provider Demographics
NPI:1861701344
Name:COOPER, MEKENZIE (APRN)
Entity type:Individual
Prefix:MS
First Name:MEKENZIE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 E 1200 S STE 201
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6904
Mailing Address - Country:US
Mailing Address - Phone:801-224-3014
Mailing Address - Fax:801-224-4914
Practice Address - Street 1:361 E 1200 S STE 201
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-224-3014
Practice Address - Fax:801-224-4914
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5646800-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid
UT260022408OtherRAILROAD MEDICARE
UT260022408OtherRAILROAD MEDICARE