Healthcare Provider Details

I. General information

NPI: 1649713009
Provider Name (Legal Business Name): MRS. MELISSA LYNN COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2016
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

2285 ELWOOD LN
NORMAL IL
61761-5467
US

V. Phone/Fax

Practice location:
  • Phone: 309-820-3535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043105401
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: