Provider Demographics
NPI:1609052398
Name:COOK, LYDIA CAUTHREN (NP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:CAUTHREN
Last Name:COOK
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL PARK DR
Practice Address - Street 2:STE 310
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2948
Practice Address - Country:US
Practice Address - Phone:704-403-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5000969363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1395Medicaid
NC2594212Medicare PIN