Provider Demographics
NPI:1255669487
Name:COOPER, BECCA NICOLE
Entity type:Individual
Prefix:
First Name:BECCA
Middle Name:NICOLE
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 1:1672 MCANDREWS RD W
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-5008
Mailing Address - Country:US
Mailing Address - Phone:952-435-5954
Mailing Address - Fax:
Practice Address - Street 1:13955 W PRESERVE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-7733
Practice Address - Country:US
Practice Address - Phone:952-890-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-29
Last Update Date:2009-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program