Provider Demographics
NPI:1003370230
Name:COOK, KIMBERLY M
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIR UNIT MEDDAC
Mailing Address - Street 2:
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4604
Mailing Address - Country:US
Mailing Address - Phone:719-526-7000
Mailing Address - Fax:
Practice Address - Street 1:1725 E BOULDER ST STE 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5740
Practice Address - Country:US
Practice Address - Phone:719-365-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
COPA.0006218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider