1467679928 NPI number — MRS. MARY JANE COOK FNP

Table of content: MRS. MARY JANE COOK FNP (NPI 1467679928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467679928 NPI number — MRS. MARY JANE COOK FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOK
Provider First Name:
MARY
Provider Middle Name:
JANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467679928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD
Provider Second Line Business Mailing Address:
A201
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-884-2976
Provider Business Mailing Address Fax Number:
517-432-3928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
804 SERVICE ROAD
Provider Second Line Business Practice Location Address:
ROOM A142
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48824-7039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-355-3503
Provider Business Practice Location Address Fax Number:
517-432-3742
Provider Enumeration Date:
04/19/2007

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: 363LF0000X , with the licence number:  4704114553 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5202009 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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