Provider Demographics
NPI:1851724165
Name:COOK, KEVIN DWAYNE (CPS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DWAYNE
Last Name:COOK
Suffix:
Gender:M
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 LINE CIR
Mailing Address - Street 2:#2
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3336
Mailing Address - Country:US
Mailing Address - Phone:404-838-9936
Mailing Address - Fax:
Practice Address - Street 1:1621 LINE CIR
Practice Address - Street 2:#2
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3336
Practice Address - Country:US
Practice Address - Phone:404-838-9936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker