Basic Information
| Provider Information | |||||||||
| NPI: | 1346728730 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | KRYSTA | ||||||||
| MiddleName: | MYCHAL | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4790 COTTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453351518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376752870 | ||||||||
| FaxNumber: | 9376752873 | ||||||||
| Practice Location | |||||||||
| Address1: | 4790 COTTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453351518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376752870 | ||||||||
| FaxNumber: | 9376752873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | LE-00024808 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | APRN.CNP.023461 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0315026 | 05 | OH | MEDICAID |