Healthcare Provider Details

I. General information

NPI: 1396982914
Provider Name (Legal Business Name): CARISSA BETH COOPER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARISSA BETH MAYNARD

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LANTANA RD STE 202
CROSSVILLE TN
38555
US

IV. Provider business mailing address

100 LANTANA RD STE 202
CROSSVILLE TN
38555-1903
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-5141
  • Fax: 865-374-2074
Mailing address:
  • Phone: 931-484-5141
  • Fax: 865-374-2074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberCNS-00214
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number734121
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18311
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: