Provider Demographics
NPI:1174594865
Name:COOPER, LESLIE JO (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:JO
Last Name:COOPER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:JO
Other - Last Name:MILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:302 WEST MAIN ST
Mailing Address - City:WARSAW
Mailing Address - State:KY
Mailing Address - Zip Code:41095
Mailing Address - Country:US
Mailing Address - Phone:859-567-2754
Mailing Address - Fax:859-567-5108
Practice Address - Street 1:302 WEST MAIN ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:KY
Practice Address - Zip Code:41095
Practice Address - Country:US
Practice Address - Phone:859-567-2754
Practice Address - Fax:859-567-5108
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2345P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78001518Medicaid
KYNP00066Medicare ID - Type Unspecified
KYNP00065Medicare ID - Type Unspecified
KYNP00067Medicare ID - Type Unspecified
KY0669802Medicare ID - Type Unspecified
KY78001518Medicaid