Provider Demographics
NPI:1598415176
Name:COOPER, EARLINE
Entity Type:Individual
Prefix:
First Name:EARLINE
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 1:3005 YORKTOWN DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-5838
Mailing Address - Country:US
Mailing Address - Phone:318-540-9498
Mailing Address - Fax:
Practice Address - Street 1:2620 CENTENARY BLVD STE 142
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-3349
Practice Address - Country:US
Practice Address - Phone:318-424-5070
Practice Address - Fax:318-424-8026
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22037822593747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant