=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740779701
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEDRA DAWN COOP ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2018
-----------------------------------------------------
Last Update Date | 10/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13300 S CLEVELAND AVE STE 56
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33907-3871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-292-3871
-----------------------------------------------------
Fax | 239-244-2118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4403 E 19TH ST
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33972-1400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-432-7195
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9301536
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------