MEDICARE: DIANA L COOPER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	202124-30	WI

General Provider Information

NPI Number	:	1023284114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA L COOPER RN

Provider Business Mailing Address
First Line	:	7635 W OKLAHOMA AVE
Second Line	:	SUITE 202
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3600
Country	:	US
Telephone Number	:	414-327-9152
Fax Number	:

Provider Business Practice Location Address
First Line	:	7635 W OKLAHOMA AVE
Second Line	:	SUITE 202
City	:	MILWAUKEE
State	:	WI
Zip	:	53219-3600
Country	:	US
Telephone Number	:	414-327-9152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	05/08/2008

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