Basic Information
| Provider Information | |||||||||
| NPI: | 1982798609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | CLARICE | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BSN, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANDERSON | ||||||||
| OtherFirstName: | CLARICE | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | BSN, RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 880 | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454091 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 MISSION DRIVE | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNATIUS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598650308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067453525 | ||||||||
| FaxNumber: | 4067454091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | RN22954 | MT | N | Nursing Service Providers | Registered Nurse | Community Health | 163W00000X | RN22954 | MT | Y | Nursing Service Providers | Registered Nurse |
No ID Information.