Provider Demographics
NPI:1619168473
Name:COOKE, SHANNON M (WHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:M
Last Name:COOKE
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:330-C PELHAM ROAD
Mailing Address - Street 2:SUITE B-102
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3534
Mailing Address - Country:US
Mailing Address - Phone:864-412-8424
Mailing Address - Fax:864-412-8012
Practice Address - Street 1:330-C PELHAM ROAD
Practice Address - Street 2:SUITE B-102
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2961
Practice Address - Country:US
Practice Address - Phone:864-412-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3302363LW0102X
OH08967363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA26458157Medicare PIN