Provider Demographics
NPI:1487143665
Name:COOPER, SHONNDA RENEE (LPN)
Entity type:Individual
Prefix:MS
First Name:SHONNDA
Middle Name:RENEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13313 142ND ST FL 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11436-2140
Mailing Address - Country:US
Mailing Address - Phone:646-472-4558
Mailing Address - Fax:
Practice Address - Street 1:2244 BLASS DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6479
Practice Address - Country:US
Practice Address - Phone:646-472-4558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217265-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty