Healthcare Provider Details

I. General information

NPI: 1215720867
Provider Name (Legal Business Name): CHERON COPELAND NDTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3344 MARINA RD APT 204
SOUTH MILWAUKEE WI
53172-3963
US

IV. Provider business mailing address

3344 MARINA RD APT 204
SOUTH MILWAUKEE WI
53172-3963
US

V. Phone/Fax

Practice location:
  • Phone: 931-637-4628
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number86374592
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: