Healthcare Provider Details

I. General information

NPI: 1003011222
Provider Name (Legal Business Name): WYNNA GAIL COOK MSCCCSLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LIFE CARE WAY
BARDSTOWN KY
40004-2059
US

IV. Provider business mailing address

6819 NAT ROGERS ROAD
BOSTON KY
40107
US

V. Phone/Fax

Practice location:
  • Phone: 502-348-4220
  • Fax:
Mailing address:
  • Phone: 502-549-9938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberKY-2467
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: