Basic Information
| Provider Information | |||||||||
| NPI: | 1831559798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | |||||||||
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| Credential: | ARNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3627 UNIVERSITY BLVD S STE 550 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322167401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043795986 | ||||||||
| FaxNumber: | 9045510282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2016 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | ARNP9414152 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LA2200X | ARNP9414152 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 003184432A | 05 | GA | MEDICAID | 019164600 | 05 | FL | MEDICAID |