Basic Information
| Provider Information | |||||||||
| NPI: | 1619050960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3115 LOREN LN | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619204417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173485312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 750 BROADWAY AVE E | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172385700 | ||||||||
| FaxNumber: | 2172385767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 11/16/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 41191239 | IL | Y | Nursing Service Providers | Registered Nurse | 163W00000X | R20024 | NM | N | Nursing Service Providers | Registered Nurse |
No ID Information.