Provider Demographics
NPI:1740520600
Name:COOK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
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 1:2723 S 7TH ST
Mailing Address - Street 2:STE A
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-3584
Mailing Address - Country:US
Mailing Address - Phone:812-238-1730
Mailing Address - Fax:812-242-1565
Practice Address - Street 1:3400 LAFAYETTE RD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1147
Practice Address - Country:US
Practice Address - Phone:317-291-7422
Practice Address - Fax:317-291-7433
Is Sole Proprietor?:No
Enumeration Date:2013-02-28
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004353B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN147180004Medicare PIN