Provider Demographics
NPI:1699029462
Name:COOPER, CRYSTAL ANN (APRN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:COOPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:39 CUMBERLAND GAP PLZ
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:KY
Practice Address - Zip Code:40734-4536
Practice Address - Country:US
Practice Address - Phone:606-526-9005
Practice Address - Fax:606-526-8607
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007739363LF0000X
TN19111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ007160Medicaid
KY7100225480Medicaid
KYK068550OtherMEDICARE PTAN