Healthcare Provider Details

I. General information

NPI: 1760610729
Provider Name (Legal Business Name): MOYA RACQUEL COOK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOYA RACQUEL MCELMURRY FNP

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 03/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W ST LOUIS ST
WEST FRANKFORT IL
62896
US

IV. Provider business mailing address

405 RUSHING DR
HERRIN IL
62948-3730
US

V. Phone/Fax

Practice location:
  • Phone: 618-937-3400
  • Fax: 618-937-3407
Mailing address:
  • Phone: 618-993-3300
  • Fax: 618-997-6626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209007626
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: