Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 29684 | TN |
NPI | 1003482993 |
---|---|
Provider Name | Demetrius Cook |
First Address | Olive Branch, MS 38654-6506 |
Second Address | Olive Branch, MS 38654-6506 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/06/2021 |
Last Update Date | 01/06/2021 |