Basic Information
Provider Information | |||||||||
NPI: | 1760437404 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COOK | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | K. | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1365 W. BRIERBROOK ROAD | ||||||||
Address2: |   | ||||||||
City: | GERMANTOWN | ||||||||
State: | TN | ||||||||
PostalCode: | 38138 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6624701921 | ||||||||
FaxNumber: | 9016246521 | ||||||||
Practice Location | |||||||||
Address1: | 146 TIMBER CREEK DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | CORDOVA | ||||||||
State: | TN | ||||||||
PostalCode: | 380184474 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9017514112 | ||||||||
FaxNumber: | 9017519878 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 11/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 08/01/2019 | ||||||||
NPIReactivationDate: | 10/31/2019 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R858017 | MS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 9390423 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 13922 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.