Provider Demographics
NPI:1124704861
Name:COOPER, CARA ANNE
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:ANNE
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 1:1518 CLARK SOUND CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8431
Mailing Address - Country:US
Mailing Address - Phone:843-793-8560
Mailing Address - Fax:
Practice Address - Street 1:1518 CLARK SOUND CIR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-8431
Practice Address - Country:US
Practice Address - Phone:843-793-8560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1411133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered