Healthcare Provider Details

I. General information

NPI: 1225154743
Provider Name (Legal Business Name): KEELY L COOK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1682 NE PINE ISLAND RD
CAPE CORAL FL
33909-1756
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-1600
  • Fax: 239-424-1640
Mailing address:
  • Phone: 239-424-1600
  • Fax: 239-424-1640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-000551
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: