Healthcare Provider Details

I. General information

NPI: 1922515923
Provider Name (Legal Business Name): KELCEY RAYE COOPER PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 BETHEL RD
OLIVE BRANCH MS
38654-8737
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-1290
  • Fax: 901-516-1220
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00617
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: