Provider Demographics
NPI:1417829052
Name:COOPER, SHANTANA (PMHNP)
Entity type:Individual
Prefix:
First Name:SHANTANA
Middle Name:
Last Name:COOPER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 GARDEN LILY LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-9230
Mailing Address - Country:US
Mailing Address - Phone:843-801-8306
Mailing Address - Fax:
Practice Address - Street 1:208 GARDEN LILY LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-9230
Practice Address - Country:US
Practice Address - Phone:843-801-8306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC245757363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health