Provider Demographics
NPI:1285901348
Name:COOPER, KELLI ANNE (LMT)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:ANNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9618
Mailing Address - Country:US
Mailing Address - Phone:208-640-3902
Mailing Address - Fax:
Practice Address - Street 1:6125 N SUNSHINE ST STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8688
Practice Address - Country:US
Practice Address - Phone:208-772-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60067981225700000X
TXMT109720225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist