Provider Demographics
NPI:1265617492
Name:COOK, CANDICE MIGNONNE (MED)
Entity type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:MIGNONNE
Last Name:COOK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:602 TENNESSEE ST STE C
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-2434
Mailing Address - Country:US
Mailing Address - Phone:888-507-1113
Mailing Address - Fax:
Practice Address - Street 1:602 TENNESSEE ST STE C
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-2434
Practice Address - Country:US
Practice Address - Phone:888-507-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-07
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist