Basic Information
| Provider Information | |||||||||
| NPI: | 1851571939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOKS | ||||||||
| FirstName: | CONNIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 B ST | ||||||||
| Address2: | SUITE 1570 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
| FaxNumber: | 6196153197 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 B ST | ||||||||
| Address2: | SUITE 1570 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196150439 | ||||||||
| FaxNumber: | 6196153197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 07/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 23662 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.