Basic Information
| Provider Information | |||||||||
| NPI: | 1275859878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOPER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RD LD/N | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9033 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349959033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722234916 | ||||||||
| FaxNumber: | 7722232887 | ||||||||
| Practice Location | |||||||||
| Address1: | 3496 NW FEDERAL HWY | ||||||||
| Address2: | STE F | ||||||||
| City: | JENSEN BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349574441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722234916 | ||||||||
| FaxNumber: | 7722232887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | ND4025 | FL | Y | Dietary & Nutritional Service Providers | Nutritionist |
No ID Information.