MEDICARE: DIJAH COOPER LVN

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	164X00000X	Licensed Vocational Nurse	200366	CA

General Provider Information

NPI Number	:	1407748569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIJAH COOPER LVN

Provider Business Mailing Address
First Line	:	6300 W LAKE MEAD BLVD APT 2062
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-6424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6300 W LAKE MEAD BLVD APT 2062
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-6424
Country	:	US
Telephone Number	:	760-559-3052
Fax Number	:

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

Provider Enumeration Date	:	07/15/2025
Last Update Date	:	07/15/2025

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