Healthcare Provider Details

I. General information

NPI: 1487575833
Provider Name (Legal Business Name): DELVONTA D COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHAWNTAY M COOPER

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14422 OLD RIDGE RD
BEAVERDAM VA
23015-1604
US

IV. Provider business mailing address

14422 OLD RIDGE RD
BEAVERDAM VA
23015-1604
US

V. Phone/Fax

Practice location:
  • Phone: 804-844-6934
  • Fax:
Mailing address:
  • Phone: 804-844-6934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: