Provider Demographics
NPI:1447487053
Name:COOPER, KATHRINE AMANDA (MD)
Entity type:Individual
Prefix:
First Name:KATHRINE
Middle Name:AMANDA
Last Name:COOPER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRINE
Other - Middle Name:AMANDA
Other - Last Name:WENTLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:
Practice Address - Street 1:4499 220TH AVE
Practice Address - Street 2:
Practice Address - City:REED CITY
Practice Address - State:MI
Practice Address - Zip Code:49677-8593
Practice Address - Country:US
Practice Address - Phone:231-832-5817
Practice Address - Fax:231-832-8260
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094199207RH0003X, 207RH0003X
IL036132423208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics