Provider Demographics
NPI:1942612247
Name:COOK, MELINDA MARIE
Entity Type:Individual
Prefix:MS
First Name:MELINDA
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 1:6571 BEVERLY DR.
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-1841
Mailing Address - Country:US
Mailing Address - Phone:440-310-0088
Mailing Address - Fax:
Practice Address - Street 1:6571 BEVERLY DR
Practice Address - Street 2:
Practice Address - City:PARMA HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-3824
Practice Address - Country:US
Practice Address - Phone:440-310-0088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-21
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN163626164W00000X
OH2944541172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2944541Medicaid
OH0193269Medicaid