Provider Demographics
NPI:1992494181
Name:COOPER, KENNEDY ROCHELLE
Entity type:Individual
Prefix:
First Name:KENNEDY
Middle Name:ROCHELLE
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19016 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-1448
Mailing Address - Country:US
Mailing Address - Phone:313-820-4286
Mailing Address - Fax:
Practice Address - Street 1:2521 N ELMS RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9423
Practice Address - Country:US
Practice Address - Phone:866-498-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703127982164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse