Healthcare Provider Details

I. General information

NPI: 1720109846
Provider Name (Legal Business Name): TAMMY LYVONNE COOPER APN-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12522 GREAT PARK CIR #303
GERMANTOWN MD
20876
US

IV. Provider business mailing address

PO BOX 2718
GERMANTOWN MD
20875-2718
US

V. Phone/Fax

Practice location:
  • Phone: 240-301-4866
  • Fax:
Mailing address:
  • Phone: 240-301-4866
  • Fax: 848-213-0287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00372800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number26NR11441600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number26NR11441600
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR233355
License Number StateMD
# 5
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP500005960
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: