Provider Demographics
NPI:1760610729
Name:COOK, MOYA RACQUEL (FNP)
Entity Type:Individual
Prefix:
First Name:MOYA
Middle Name:RACQUEL
Last Name:COOK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MOYA
Other - Middle Name:RACQUEL
Other - Last Name:MCELMURRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:405 RUSHING DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3730
Mailing Address - Country:US
Mailing Address - Phone:618-993-3300
Mailing Address - Fax:618-997-6626
Practice Address - Street 1:502 W ST LOUIS ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896
Practice Address - Country:US
Practice Address - Phone:618-937-3400
Practice Address - Fax:618-937-3407
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
80077375OtherMEDICARE RAILROAD
33308OtherHEALTH ALLIANCE
103788OtherHEALTHLINK
IL10019630OtherATTACHMENT
10800012002OtherHEALTH CONNECT
IL36062597Medicaid
80077375OtherMEDICARE RAILROAD
ILD15096Medicare UPIN
IL36062597Medicaid