Provider Demographics
NPI:1003571175
Name:COOPER, HERTAYZIA ESHAY
Entity Type:Individual
Prefix:
First Name:HERTAYZIA
Middle Name:ESHAY
Last Name:COOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 SE 42ND PL
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32641-9268
Mailing Address - Country:US
Mailing Address - Phone:352-283-3287
Mailing Address - Fax:
Practice Address - Street 1:3019 NE 20TH WAY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3395
Practice Address - Country:US
Practice Address - Phone:352-283-3287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL87-3080428374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87-3080428OtherCOMPANIONSHIP & HOMEMAKER