Healthcare Provider Details

I. General information

NPI: 1619753985
Provider Name (Legal Business Name): SHARON COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2261 SW IVORY RD
PORT SAINT LUCIE FL
34953-2142
US

IV. Provider business mailing address

2261 SW IVORY RD
PORT SAINT LUCIE FL
34953-2142
US

V. Phone/Fax

Practice location:
  • Phone: 772-418-9099
  • Fax:
Mailing address:
  • Phone: 772-418-9099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: