Provider Demographics
NPI:1215023502
Name:COOPER-BROWN, CAROL DIANE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:DIANE
Last Name:COOPER-BROWN
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 1:3701 POWERS RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2302
Mailing Address - Country:US
Mailing Address - Phone:321-624-7506
Mailing Address - Fax:
Practice Address - Street 1:3701 POWERS RIDGE CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-2302
Practice Address - Country:US
Practice Address - Phone:407-294-6679
Practice Address - Fax:407-294-6679
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230432500Medicaid