MEDICARE: HEIDI JO COOPER PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	AP61677729	WA
2	363LP0200X	Pediatric Nurse Practitioner	NP74551	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629661210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI JO COOPER PNP

Provider Business Mailing Address
First Line	:	2310 N MOLTER RD STE 206
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-8621
Country	:	US
Telephone Number	:	509-289-4969
Fax Number	:	509-289-4968

Provider Business Practice Location Address
First Line	:	2310 N MOLTER RD STE 206
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-8621
Country	:	US
Telephone Number	:	509-289-4969
Fax Number	:	509-289-4968

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/16/2021
Last Update Date	:	02/04/2026

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Directions to “ HEIDI JO COOPER PNP” Practice Location

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