Provider Demographics
NPI:1548928435
Name:COOPER, DIANA LACY (CHW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LACY
Last Name:COOPER
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9725
Mailing Address - Country:US
Mailing Address - Phone:541-251-2520
Mailing Address - Fax:
Practice Address - Street 1:401 FIR ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9222
Practice Address - Country:US
Practice Address - Phone:541-469-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000001068172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker