Healthcare Provider Details

I. General information

NPI: 1053949917
Provider Name (Legal Business Name): COURTNEY NICOLE COOPER AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28078 BAXTER RD STE 314
MURRIETA CA
92563-1404
US

IV. Provider business mailing address

28078 BAXTER RD STE 314
MURRIETA CA
92563-1404
US

V. Phone/Fax

Practice location:
  • Phone: 951-894-4665
  • Fax:
Mailing address:
  • Phone: 951-894-4665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95014237
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: