Provider Demographics
NPI:1851106694
Name:COOPER, CAMERON MACKENZIE
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:MACKENZIE
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 1:3432 BANDERA RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5867
Mailing Address - Country:US
Mailing Address - Phone:817-781-4059
Mailing Address - Fax:
Practice Address - Street 1:3432 BANDERA RANCH RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-5867
Practice Address - Country:US
Practice Address - Phone:817-781-4059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist