Provider Demographics
NPI:1760050306
Name:COOPER, KANTRELLE DAMONE (LPN)
Entity Type:Individual
Prefix:
First Name:KANTRELLE
Middle Name:DAMONE
Last Name:COOPER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W HONADEL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-2650
Mailing Address - Country:US
Mailing Address - Phone:414-435-2005
Mailing Address - Fax:
Practice Address - Street 1:2700 W HONADEL BLVD
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-2650
Practice Address - Country:US
Practice Address - Phone:414-435-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI325962-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse