Healthcare Provider Details

I. General information

NPI: 1104192236
Provider Name (Legal Business Name): OCTAVIA COOPER BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S BROAD ST
PHILADELPHIA PA
19145-2328
US

IV. Provider business mailing address

5 FIR CT
SICKLERVILLE NJ
08081-2118
US

V. Phone/Fax

Practice location:
  • Phone: 215-339-4343
  • Fax:
Mailing address:
  • Phone: 856-228-8545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN-322666L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: