Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 4704266386 | MI |
NPI | 1013408400 |
---|---|
Provider Name | Amanda Cook |
First Address | Flint, MI 48507-2919 |
Second Address | Flint, MI 48507 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2018 |
Last Update Date | 22/06/2018 |