Provider Demographics
NPI:1871862409
Name:COOK, STACIE WARD (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:WARD
Last Name:COOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:M
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 16568
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-6568
Mailing Address - Country:US
Mailing Address - Phone:904-472-2300
Mailing Address - Fax:904-472-2330
Practice Address - Street 1:836 PRUDENTIAL DRIVE
Practice Address - Street 2:SUITE 1103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8338
Practice Address - Country:US
Practice Address - Phone:904-398-9499
Practice Address - Fax:904-398-0118
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111536207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology