Provider Demographics
NPI:1922067206
Name:COOK, MAVIS REBECCA (CRNA)
Entity Type:Individual
Prefix:
First Name:MAVIS
Middle Name:REBECCA
Last Name:COOK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 RUTLEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-3051
Mailing Address - Country:US
Mailing Address - Phone:843-669-2808
Mailing Address - Fax:
Practice Address - Street 1:555 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2617
Practice Address - Country:US
Practice Address - Phone:843-777-8752
Practice Address - Fax:843-777-8705
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0066Medicaid