Healthcare Provider Details

I. General information

NPI: 1760991061
Provider Name (Legal Business Name): ELIZABETH ROTHELL COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4335 RICHMOND AVE
SHREVEPORT LA
71106-1417
US

IV. Provider business mailing address

219 RADBROOK DR
BOSSIER CITY LA
71112-8610
US

V. Phone/Fax

Practice location:
  • Phone: 318-458-8403
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN065294
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: