MEDICARE: TONI L. COOPER RN, MSN, CDE

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	163WD0400X	Diabetes Educator Registered Nurse	R501069	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R501069	OTHER	MS	LICENSE NUMBER

General Provider Information

NPI Number	:	1477872273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONI L. COOPER RN, MSN, CDE

Provider Business Mailing Address
First Line	:	1040 RIVER OAKS DR
Second Line	:	STE. 302
City	:	JACKSON
State	:	MS
Zip	:	39232-9530
Country	:	US
Telephone Number	:	601-939-9923
Fax Number	:	601-939-9924

Provider Business Practice Location Address
First Line	:	1040 RIVER OAKS DR
Second Line	:	STE. 302
City	:	JACKSON
State	:	MS
Zip	:	39232-9530
Country	:	US
Telephone Number	:	601-939-9923
Fax Number	:	601-939-9924

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

Provider Enumeration Date	:	05/19/2010
Last Update Date	:	05/19/2010

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