Individual
MARYANN COOPER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1912 HARBOR ISLAND DR, ORANGE PARK, FL 32003-7257
(904) 278-5345
Mailing address
1912 HARBOR ISLAND DR, ORANGE PARK, FL 32003-7257
(904) 278-5345
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
01-08-113-05
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
230100800
MEDICAID PROVIDER NUMBER
FL
Enumeration date
05/21/2008
Last updated
05/21/2008
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