Healthcare Provider Details

I. General information

NPI: 1629740642
Provider Name (Legal Business Name): CHARLOTTE ANNE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/27/2023
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

175 SPALDING CREEK CT
ATLANTA GA
30350-1142
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone: 770-789-3696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN254690
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN254690
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: