1568465136 NPI number — MS. KATHY ADRIANNE COOK PORTER NP

Table of content: MS. KATHY ADRIANNE COOK PORTER NP (NPI 1568465136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568465136 NPI number — MS. KATHY ADRIANNE COOK PORTER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COOK PORTER
Provider First Name:
KATHY
Provider Middle Name:
ADRIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOK
Provider Other First Name:
KATHY
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568465136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 W WHEATLAND RD STE 440
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75237-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-298-4300
Provider Business Mailing Address Fax Number:
972-298-8903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 W WHEATLAND RD STE 440
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75237-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-298-4300
Provider Business Practice Location Address Fax Number:
972-298-8903
Provider Enumeration Date:
05/27/2005

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: 363LW0102X , with the licence number:  AP111291 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1479685 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".