Provider Demographics
NPI:1124628300
Name:COOPER, KELLY M
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
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 1:510 TENANT CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:MD
Mailing Address - Zip Code:21663-2873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1013 S TALBOT ST
Practice Address - Street 2:
Practice Address - City:SAINT MICHAELS
Practice Address - State:MD
Practice Address - Zip Code:21663-2637
Practice Address - Country:US
Practice Address - Phone:954-298-9913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2775152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist