Provider Demographics
NPI:1639431273
Name:COOPER, SALLY J (CPM LM)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:J
Last Name:COOPER
Suffix:
Gender:F
Credentials:CPM LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S MOUNT SHASTA BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2524
Mailing Address - Country:US
Mailing Address - Phone:530-859-3949
Mailing Address - Fax:
Practice Address - Street 1:304 S MOUNT SHASTA BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2524
Practice Address - Country:US
Practice Address - Phone:530-859-3949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife