Healthcare Provider Details

I. General information

NPI: 1245071844
Provider Name (Legal Business Name): KATELYN COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31989 GRIFFITH DR
GALENA MD
21635-1413
US

IV. Provider business mailing address

31989 GRIFFITH DR
GALENA MD
21635-1413
US

V. Phone/Fax

Practice location:
  • Phone: 443-480-3773
  • Fax:
Mailing address:
  • Phone: 443-480-3773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR-233337
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: