1518509462 NPI number — MRS. CASSIE JOANNE COOK RD, LD

Table of content: MRS. CASSIE JOANNE COOK RD, LD (NPI 1518509462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518509462 NPI number — MRS. CASSIE JOANNE COOK RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOK
Provider First Name:
CASSIE
Provider Middle Name:
JOANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CONN
Provider Other First Name:
CASSIE
Provider Other Middle Name:
JOANNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RD, LD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1518509462
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2950 S SERVICE RD APT 4134
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73160-5668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-240-2779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
909 26TH AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73069-6366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-801-2323
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  2428 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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