Healthcare Provider Details

I. General information

NPI: 1346489168
Provider Name (Legal Business Name): LISA RENE COOK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12865 POINTE DEL MAR WAY #160
DEL MAR CA
92014-3860
US

IV. Provider business mailing address

12865 POINTE DEL MAR WAY #160
DEL MAR CA
92014-3860
US

V. Phone/Fax

Practice location:
  • Phone: 858-350-7546
  • Fax:
Mailing address:
  • Phone: 858-350-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP3276
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: