Provider Demographics
NPI:1174003404
Name:COOPER, SHANNON DENISE (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:DENISE
Last Name:COOPER
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:DENISE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:8029 DUSTY WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1915
Mailing Address - Country:US
Mailing Address - Phone:817-266-7468
Mailing Address - Fax:
Practice Address - Street 1:8029 DUSTY WAY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-1915
Practice Address - Country:US
Practice Address - Phone:817-810-0660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX703695163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse