Healthcare Provider Details

I. General information

NPI: 1659937100
Provider Name (Legal Business Name): DEJA COOPER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N91W15750 FALLS PKWY
MENOMONEE FALLS WI
53051-2301
US

IV. Provider business mailing address

5644 N 35TH ST
MILWAUKEE WI
53209-4032
US

V. Phone/Fax

Practice location:
  • Phone: 262-532-1100
  • Fax:
Mailing address:
  • Phone: 414-524-9624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: