Provider Demographics
NPI:1588804629
Name:COOK, STACIA LYNNETTE (CNA)
Entity Type:Individual
Prefix:MISS
First Name:STACIA
Middle Name:LYNNETTE
Last Name:COOK
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20290 BENTLER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1373
Mailing Address - Country:US
Mailing Address - Phone:313-384-8543
Mailing Address - Fax:313-531-3056
Practice Address - Street 1:20290 BENTLER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1373
Practice Address - Country:US
Practice Address - Phone:313-384-8543
Practice Address - Fax:313-531-3056
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI237185110198376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide