Healthcare Provider Details

I. General information

NPI: 1255669487
Provider Name (Legal Business Name): BECCA NICOLE COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2009
Last Update Date: 11/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13955 W PRESERVE BLVD SUITE 200
BURNSVILLE MN
55337-7733
US

IV. Provider business mailing address

1672 MCANDREWS RD W
BURNSVILLE MN
55337-5008
US

V. Phone/Fax

Practice location:
  • Phone: 952-890-0804
  • Fax:
Mailing address:
  • Phone: 952-435-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: