Provider Demographics
NPI:1225765159
Name:COOPER, CRYSTAL RENEE (IBCLC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RENEE
Last Name:COOPER
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2421 CHESSTAL ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2521
Mailing Address - Country:US
Mailing Address - Phone:808-223-0057
Mailing Address - Fax:
Practice Address - Street 1:2421 CHESSTAL ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2521
Practice Address - Country:US
Practice Address - Phone:808-223-0057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIL-56521174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN