Provider Demographics
NPI:1790939742
Name:COOK, STEPHANIE (MT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S 2ND AVE APT 5C
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6920
Mailing Address - Country:US
Mailing Address - Phone:208-604-3185
Mailing Address - Fax:
Practice Address - Street 1:2100 S 2ND AVE APT 5C
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6920
Practice Address - Country:US
Practice Address - Phone:208-604-3185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other