Provider Demographics
NPI:1972964872
Name:COOPER, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:STROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11984 WENDT RD
Mailing Address - Street 2:
Mailing Address - City:KENDRICK
Mailing Address - State:ID
Mailing Address - Zip Code:83537-5047
Mailing Address - Country:US
Mailing Address - Phone:509-552-6605
Mailing Address - Fax:
Practice Address - Street 1:11984 WENDT RD
Practice Address - Street 2:
Practice Address - City:KENDRICK
Practice Address - State:ID
Practice Address - Zip Code:83537-5047
Practice Address - Country:US
Practice Address - Phone:509-552-6605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide