Provider Demographics
NPI:1285647313
Name:COOPER, HEATHER MICHELLE (CRNA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2930
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-2930
Mailing Address - Country:US
Mailing Address - Phone:844-468-9496
Mailing Address - Fax:855-630-1300
Practice Address - Street 1:975 E. THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-602-8400
Practice Address - Fax:423-602-8401
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN129057163W00000X
TNAPN12282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3638268Medicaid
GA616233034AMedicaid
TN4156549OtherBLUE CROSS BLUE SHIELD TN
N371089OtherWELLCARE (GA MEDICAID)
AL009911541Medicaid
NC8052756Medicaid
P00457980OtherRAILROAD MEDICARE
TN3638268Medicaid