Provider Demographics
NPI:1205255122
Name:COOPER, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
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 1:1589 SULPHUR SPRING RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-2542
Mailing Address - Country:US
Mailing Address - Phone:410-536-5400
Mailing Address - Fax:410-737-2168
Practice Address - Street 1:808 LANDMARK DR
Practice Address - Street 2:SUITE 122
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-4983
Practice Address - Country:US
Practice Address - Phone:410-760-3588
Practice Address - Fax:410-760-3604
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00411133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal