Healthcare Provider Details

I. General information

NPI: 1063716900
Provider Name (Legal Business Name): ANDREW COOK LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

398 NEPONSET AVE
DORCHESTER MA
02122-3134
US

IV. Provider business mailing address

1135 MORTON ST
MATTAPAN MA
02126-2834
US

V. Phone/Fax

Practice location:
  • Phone: 617-282-3200
  • Fax: 617-282-8201
Mailing address:
  • Phone: 617-533-2300
  • Fax: 617-533-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLN86904
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: