MEDICARE: MELISSA COOPER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	668764	NY

General Provider Information

NPI Number	:	1255966214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA COOPER RN

Provider Business Mailing Address
First Line	:	1130 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-1255
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 PARK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10128-1255
Country	:	US
Telephone Number	:	212-369-9600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	03/10/2020

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