Healthcare Provider Details

I. General information

NPI: 1508772377
Provider Name (Legal Business Name): SHAKITA SHANTEL COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 PERSHING AVE
BUFFALO NY
14211-2915
US

IV. Provider business mailing address

83 PERSHING AVE
BUFFALO NY
14211-2915
US

V. Phone/Fax

Practice location:
  • Phone: 716-777-6990
  • Fax:
Mailing address:
  • Phone: 716-777-6990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number322409
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: