Healthcare Provider Details

I. General information

NPI: 1275105983
Provider Name (Legal Business Name): BRANDY NICOLE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 W MAIN ST
LAMAR AR
72846-8195
US

IV. Provider business mailing address

4196 HIGHWAY 62 412 STE A
HARDY AR
72542-8002
US

V. Phone/Fax

Practice location:
  • Phone: 479-703-5000
  • Fax: 870-895-2164
Mailing address:
  • Phone: 870-856-1202
  • Fax: 870-856-2107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number216171
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: