Healthcare Provider Details

I. General information

NPI: 1215711445
Provider Name (Legal Business Name): TANIA R COOPER RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6726 E PREMIUM ST
LONG BEACH CA
90808-4135
US

IV. Provider business mailing address

6726 E PREMIUM ST
LONG BEACH CA
90808-4135
US

V. Phone/Fax

Practice location:
  • Phone: 626-664-3420
  • Fax:
Mailing address:
  • Phone: 626-664-3420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number723597
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: