Provider Demographics
NPI:1215370887
Name:COOK, DESHEA LYNN
Entity Type:Individual
Prefix:
First Name:DESHEA
Middle Name:LYNN
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 1:224 GOLDENEYE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-1626
Mailing Address - Country:US
Mailing Address - Phone:817-939-9152
Mailing Address - Fax:
Practice Address - Street 1:224 GOLDENEYE LN
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1626
Practice Address - Country:US
Practice Address - Phone:817-939-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor