Healthcare Provider Details

I. General information

NPI: 1013655851
Provider Name (Legal Business Name): TARVIS COPELAND LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 E APACHE ST
FARMINGTON NM
87401-6925
US

IV. Provider business mailing address

607 E APACHE ST
FARMINGTON NM
87401-6925
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-2012
  • Fax:
Mailing address:
  • Phone: 505-326-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberGA056BIC
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: