MEDICARE: MISS STACIA LYNNETTE COOK CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	237185110198	MI

General Provider Information

NPI Number	:	1588804629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STACIA LYNNETTE COOK CNA

Provider Business Mailing Address
First Line	:	20290 BENTLER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1373
Country	:	US
Telephone Number	:	313-384-8543
Fax Number	:	313-531-3056

Provider Business Practice Location Address
First Line	:	20290 BENTLER ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-1373
Country	:	US
Telephone Number	:	313-384-8543
Fax Number	:	313-531-3056

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2009
Last Update Date	:	03/03/2009

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