Healthcare Provider Details

I. General information

NPI: 1225765159
Provider Name (Legal Business Name): CRYSTAL RENEE COOPER IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 CHESSTAL ST
SAINT CHARLES MO
63301-2521
US

IV. Provider business mailing address

2421 CHESSTAL ST
SAINT CHARLES MO
63301-2521
US

V. Phone/Fax

Practice location:
  • Phone: 808-223-0057
  • Fax:
Mailing address:
  • Phone: 808-223-0057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-56521
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: