Provider Demographics
NPI:1508148990
Name:COOK, SIDNEY (FNP)
Entity Type:Individual
Prefix:MR
First Name:SIDNEY
Middle Name:
Last Name:COOK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 GOODMAN RD E STE 115
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9304
Mailing Address - Country:US
Mailing Address - Phone:662-890-5555
Mailing Address - Fax:662-890-8899
Practice Address - Street 1:3451 GOODMAN RD E STE 115
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9304
Practice Address - Country:US
Practice Address - Phone:662-890-5555
Practice Address - Fax:662-890-8899
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR854897363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily