Provider Demographics
NPI:1336657469
Name:COOPER, KEDEEMYA S (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:KEDEEMYA
Middle Name:S
Last Name:COOPER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 MEADOWLARK COMMONS CT APT 203
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-5872
Mailing Address - Country:US
Mailing Address - Phone:229-221-9850
Mailing Address - Fax:
Practice Address - Street 1:255 FULLER ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-2212
Practice Address - Country:US
Practice Address - Phone:229-221-9850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer