Healthcare Provider Details

I. General information

NPI: 1699029462
Provider Name (Legal Business Name): CRYSTAL ANN COOPER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 CUMBERLAND GAP PLZ
GRAY KY
40734-4536
US

IV. Provider business mailing address

PO BOX 1325
CORBIN KY
40702-1325
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-9005
  • Fax: 606-526-8607
Mailing address:
  • Phone: 606-526-8131
  • Fax: 606-528-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3007739
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19111
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: