Healthcare Provider Details

I. General information

NPI: 1336104322
Provider Name (Legal Business Name): STACIE MICHELE COOPER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 SW 152ND ST
MIAMI FL
33177-1111
US

IV. Provider business mailing address

9130 S DADELAND BLVD STE 1202
MIAMI FL
33156-7848
US

V. Phone/Fax

Practice location:
  • Phone: 786-596-4300
  • Fax:
Mailing address:
  • Phone: 786-888-8820
  • Fax: 760-674-3845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 18243
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110738
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: