Provider Demographics
NPI:1528017670
Name:COOK, LISA R (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:COOK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11069 FRISCO LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-3685
Mailing Address - Country:US
Mailing Address - Phone:810-869-4894
Mailing Address - Fax:
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-244-0411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011749367500000X
MI4704221614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM77150116Medicare PIN