Healthcare Provider Details

I. General information

NPI: 1104460617
Provider Name (Legal Business Name): NICOLE COOPER REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 BURNET AVE
CINCINNATI OH
45229-3014
US

IV. Provider business mailing address

3114 MARCH TER
CINCINNATI OH
45239-5417
US

V. Phone/Fax

Practice location:
  • Phone: 614-571-8545
  • Fax:
Mailing address:
  • Phone: 614-571-8545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.486260
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: