=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609439868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LATARSHA COOPER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2019
-----------------------------------------------------
Last Update Date | 04/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9711 DAVID TAYLOR DR APT 228
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28262-2376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-564-0949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8410 UNIVERSITY STATION CIR APT 1312
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28269-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-564-0949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224P00000X
-----------------------------------------------------
Taxonomy Name | Prosthetist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------