Provider Demographics
NPI:1669134300
Name:COOPER, MELISSA SHUNTA (CMA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SHUNTA
Last Name:COOPER
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4374
Mailing Address - Country:US
Mailing Address - Phone:706-340-9566
Mailing Address - Fax:
Practice Address - Street 1:4600 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4374
Practice Address - Country:US
Practice Address - Phone:706-340-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20268794737202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA87-1622293OtherELITE MOBILE PHLEBOTOMIST OF GA. LLC