Provider Demographics
NPI:1780391284
Name:COOKE, SHAVON
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:
Last Name:COOKE
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 1:1021 EDEN WAY NORTH PMB 339
Mailing Address - Street 2:STE 118
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-759-1619
Mailing Address - Fax:
Practice Address - Street 1:168 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-1835
Practice Address - Country:US
Practice Address - Phone:757-759-1619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
VA43990-167-465-8163202K00000X, 2083T0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical ToxicologyGroup - Single Specialty
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology