Provider Demographics
NPI:1033981907
Name:COOPER-NNODIM, TYLANIA A (CRANIAL PROSTHESIS)
Entity Type:Individual
Prefix:MRS
First Name:TYLANIA
Middle Name:A
Last Name:COOPER-NNODIM
Suffix:
Gender:F
Credentials:CRANIAL PROSTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 FELLOWSHIP RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-1234
Mailing Address - Country:US
Mailing Address - Phone:908-793-9125
Mailing Address - Fax:
Practice Address - Street 1:73 HILLCREST LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1235
Practice Address - Country:US
Practice Address - Phone:609-553-4967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GATHEQHQ9CEC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier