Provider Demographics
NPI:1477091866
Name:COOPER, LUTISSE
Entity Type:Individual
Prefix:MRS
First Name:LUTISSE
Middle Name:
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 1:2520 BREAKWATER CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-2675
Mailing Address - Country:US
Mailing Address - Phone:301-932-5443
Mailing Address - Fax:
Practice Address - Street 1:2520 BREAKWATER COURT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601
Practice Address - Country:US
Practice Address - Phone:301-932-5443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide