MEDICARE: MIKAYLA EMERALD COOPER RD

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	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1518616374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA EMERALD COOPER RD

Provider Business Mailing Address
First Line	:	2626 W PERSCHON CIR
Second Line	:
City	:	BLUFFDALE
State	:	UT
Zip	:	84065-3743
Country	:	US
Telephone Number	:	801-503-5549
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 MARSH LANDING BLVD # 100
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-1416
Country	:	US
Telephone Number	:	904-947-0531
Fax Number	:

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

Provider Enumeration Date	:	03/21/2022
Last Update Date	:	03/21/2022

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