Healthcare Provider Details

I. General information

NPI: 1174594865
Provider Name (Legal Business Name): LESLIE JO COOPER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LESLIE JO MILES RN

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 WEST MAIN ST
WARSAW KY
41095
US

IV. Provider business mailing address

PO BOX 128 302 WEST MAIN ST
WARSAW KY
41095
US

V. Phone/Fax

Practice location:
  • Phone: 859-567-2754
  • Fax: 859-567-5108
Mailing address:
  • Phone: 859-567-2754
  • Fax: 859-567-5108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2345P
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: