Healthcare Provider Details

I. General information

NPI: 1497923445
Provider Name (Legal Business Name): KATHLYN R. COOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 N. NORTH HILLS BLVD.
FAYETTEVILLE AR
72703-4424
US

IV. Provider business mailing address

PO BOX 550
LOWELL AR
72745-0550
US

V. Phone/Fax

Practice location:
  • Phone: 479-463-7102
  • Fax: 479-463-7864
Mailing address:
  • Phone: 479-463-7775
  • Fax: 479-463-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA102273
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberE-9453
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE-9453
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberE-9453
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-9453
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: