Provider Demographics
NPI:1396479127
Name:COOLEY, WESLIE (CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:WESLIE
Middle Name:
Last Name:COOLEY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:WESLIE
Other - Middle Name:
Other - Last Name:COOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2588 N CAMERTON PL
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4825
Mailing Address - Country:US
Mailing Address - Phone:208-817-1008
Mailing Address - Fax:
Practice Address - Street 1:4740 N PENNGROVE WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7447
Practice Address - Country:US
Practice Address - Phone:208-514-0203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-16
Last Update Date:2022-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58531363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty