Provider Demographics
NPI:1447880695
Name:HARRIS COOPER, LENISA (INDEPENDENT PROVIDER)
Entity type:Individual
Prefix:
First Name:LENISA
Middle Name:
Last Name:HARRIS COOPER
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 574
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:OH
Mailing Address - Zip Code:45628-0574
Mailing Address - Country:US
Mailing Address - Phone:614-633-5365
Mailing Address - Fax:
Practice Address - Street 1:40 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:OH
Practice Address - Zip Code:45628
Practice Address - Country:US
Practice Address - Phone:614-633-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
7103017OtherINDEPENDENT PROVIDER NUMBER
OH0323961Medicaid