Provider Demographics
NPI:1922076439
Name:COOKS, WILLETTA AUDREY (BSN, MSN, BC)
Entity Type:Individual
Prefix:MS
First Name:WILLETTA
Middle Name:AUDREY
Last Name:COOKS
Suffix:
Gender:F
Credentials:BSN, MSN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 LONNIE BECK WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4188
Mailing Address - Country:US
Mailing Address - Phone:209-956-3169
Mailing Address - Fax:
Practice Address - Street 1:7777 E FREEDOM RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9694
Practice Address - Country:US
Practice Address - Phone:209-946-4305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2243364SP0809X
KS53-45316-041363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0380913-01OtherANCC
CA2243OtherCNS
KS45316OtherARNP