Provider Demographics
NPI:1720109846
Name:COOPER, TAMMY LYVONNE (APN-C)
Entity type:Individual
Prefix:MISS
First Name:TAMMY
Middle Name:LYVONNE
Last Name:COOPER
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2718
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20875-2718
Mailing Address - Country:US
Mailing Address - Phone:240-301-4866
Mailing Address - Fax:848-213-0287
Practice Address - Street 1:12522 GREAT PARK CIR #303
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20876
Practice Address - Country:US
Practice Address - Phone:240-301-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00372800363LA2200X
NJ26NR11441600163WM0705X, 163WP0808X
MDR233355363LA2200X
DCNP500005960363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0325279Medicaid
NJ290896Medicare PIN