Healthcare Provider Details

I. General information

NPI: 1043425911
Provider Name (Legal Business Name): SONYA COOPER L.M.T #5343
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2007
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 DEREK JAMES DR
EDGEWOOD NM
87015-9707
US

IV. Provider business mailing address

10255 JARASH PL NE
ALBUQUERQUE NM
87122-3317
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-5168
  • Fax:
Mailing address:
  • Phone: 505-217-5168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5343
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: