MEDICARE: KIM COOPER NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	R639893	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	202011213A	OTHER	MS	BLUE CROSS

General Provider Information

NPI Number	:	1750316881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM COOPER NP

Provider Business Mailing Address
First Line	:	5903 RIDGEWOOD RD STE 310
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-3702
Country	:	US
Telephone Number	:	601-899-3310
Fax Number	:

Provider Business Practice Location Address
First Line	:	5903 RIDGEWOOD RD STE 310
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39211-3702
Country	:	US
Telephone Number	:	601-899-3310
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	06/25/2010

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Directions to “ KIM COOPER NP” Practice Location

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