Basic Information
| Provider Information | |||||||||
| NPI: | 1285647313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2930 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462062930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444689496 | ||||||||
| FaxNumber: | 8556301300 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 E. THIRD STREET | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236028400 | ||||||||
| FaxNumber: | 4236028401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN129057 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | APN12282 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3638268 | 05 | TN | MEDICAID | 616233034A | 05 | GA | MEDICAID | 4156549 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | N371089 | 01 | WELLCARE (GA MEDICAID) | OTHER | 009911541 | 05 | AL | MEDICAID | 8052756 | 05 | NC | MEDICAID | P00457980 | 01 | RAILROAD MEDICARE | OTHER |