Provider Demographics
NPI:1871910729
Name:COOPER, AMBER LEIA (COTA)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:LEIA
Last Name:COOPER
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:MISS
Other - First Name:AMBER
Other - Middle Name:LEIA
Other - Last Name:MUMAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:9909 E 100 S
Mailing Address - Street 2:
Mailing Address - City:GREENTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46936-9163
Mailing Address - Country:US
Mailing Address - Phone:765-628-0605
Mailing Address - Fax:765-628-3639
Practice Address - Street 1:9909 E 100 S
Practice Address - Street 2:
Practice Address - City:GREENTOWN
Practice Address - State:IN
Practice Address - Zip Code:46936-9163
Practice Address - Country:US
Practice Address - Phone:765-628-0605
Practice Address - Fax:765-628-3639
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1073789467171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor