Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | RN182059 | GA |
NPI | 1023573334 |
---|---|
Provider Name | Courtney Cook |
First Address | Loganville, GA 30052-5285 |
Second Address | Loganville, GA 30052-5285 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/01/2019 |
Last Update Date | 31/01/2019 |