MEDICARE: SHAWNA L COOPER LVN

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	164X00000X	Licensed Vocational Nurse	208061	CA
2	101Y00000X	Counselor

General Provider Information

NPI Number	:	1356547897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWNA L COOPER LVN

Provider Business Mailing Address
First Line	:	PO BOX 563
Second Line	:	APT B69
City	:	PEPEEKEO
State	:	HI
Zip	:	96783-0563
Country	:	US
Telephone Number	:	808-780-5771
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 KILAUEA AVE STE A
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96720-4291
Country	:	US
Telephone Number	:	808-780-5771
Fax Number	:

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

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	04/07/2014

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