Provider Demographics
NPI:1124219191
Name:COOK, SANDRA LEE (CNM)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:COOK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10275 SW SHAMROCK LN
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:OR
Mailing Address - Zip Code:97734
Mailing Address - Country:US
Mailing Address - Phone:541-604-5097
Mailing Address - Fax:484-842-2117
Practice Address - Street 1:436 & 5TH STREET TED STEVENS WAY
Practice Address - Street 2:MANIILAQ HEALTH CENTER
Practice Address - City:KOTZEBUE
Practice Address - State:AK
Practice Address - Zip Code:99752
Practice Address - Country:US
Practice Address - Phone:541-604-5097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK612367A00000X
OR086C03015N5367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
S08892Medicare UPIN