Provider Demographics
NPI:1396392254
Name:COOKE, TIAH CHARLYE-ARLENE (NP)
Entity Type:Individual
Prefix:MS
First Name:TIAH
Middle Name:CHARLYE-ARLENE
Last Name:COOKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4408 WATCHRUN DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-6116
Mailing Address - Country:US
Mailing Address - Phone:804-347-2769
Mailing Address - Fax:
Practice Address - Street 1:5021 CRAIG RATH BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-6243
Practice Address - Country:US
Practice Address - Phone:804-592-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024178057363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics