Provider Demographics
NPI:1932681897
Name:COOK, ANNETTE MARIE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 DAVENPORT
Mailing Address - Street 2:
Mailing Address - City:ITALY
Mailing Address - State:TX
Mailing Address - Zip Code:76651-3592
Mailing Address - Country:US
Mailing Address - Phone:254-972-6369
Mailing Address - Fax:
Practice Address - Street 1:220 DAVENPORT
Practice Address - Street 2:
Practice Address - City:ITALY
Practice Address - State:TX
Practice Address - Zip Code:76651-3592
Practice Address - Country:US
Practice Address - Phone:254-972-6369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2027118225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2027118Medicaid