Healthcare Provider Details

I. General information

NPI: 1386765733
Provider Name (Legal Business Name): LAURA ELIZABETH COOPER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

3235 S TROOST AVE
TULSA OK
74105-2121
US

V. Phone/Fax

Practice location:
  • Phone: 918-494-7201
  • Fax:
Mailing address:
  • Phone: 918-693-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1401
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: