Provider Demographics
NPI:1265052047
Name:COOPER, QUIANA LATOYA (NP)
Entity type:Individual
Prefix:
First Name:QUIANA
Middle Name:LATOYA
Last Name:COOPER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21875 PINEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-7717
Mailing Address - Country:US
Mailing Address - Phone:951-238-8387
Mailing Address - Fax:
Practice Address - Street 1:6529 RIVERSIDE AVE STE 133
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3123
Practice Address - Country:US
Practice Address - Phone:951-684-2627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014362363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health