Basic Information
| Provider Information | |||||||||
| NPI: | 1629049705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALTON | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603973352 | ||||||||
| FaxNumber: | 3606041771 | ||||||||
| Practice Location | |||||||||
| Address1: | 291 C ST UNIT 110 | ||||||||
| Address2: | |||||||||
| City: | WASHOUGAL | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986712168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 05/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200250029NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP30007055 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9648171 | 05 | WA | MEDICAID |