Provider Demographics
NPI:1417629403
Name:COOPER, MELINDA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:COOPER
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 KARLI LN
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-8026
Mailing Address - Country:US
Mailing Address - Phone:228-257-9289
Mailing Address - Fax:
Practice Address - Street 1:1741 DUAL HWY
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6624
Practice Address - Country:US
Practice Address - Phone:301-337-7749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188012363LF0000X
WV117249363LF0000X
PAPA066069363LF0000X
MARN2386999363LF0000X
MDAC005797363LF0000X
MS904864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1417629403Medicaid