Basic Information
| Provider Information | |||||||||
| NPI: | 1851909162 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COOKE | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695879 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 N CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | SUMMERVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294836605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438719440 | ||||||||
| FaxNumber: | 8438715932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2020 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 24143 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP7217 | 05 | SC | MEDICAID |