Healthcare Provider Details

I. General information

NPI: 1194391391
Provider Name (Legal Business Name): CLARISSA COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2021
Last Update Date: 05/28/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7284 CONTINENTAL AVE
WARREN MI
48091-3532
US

IV. Provider business mailing address

7284 CONTINENTAL AVE
WARREN MI
48091-3532
US

V. Phone/Fax

Practice location:
  • Phone: 586-217-1494
  • Fax: 586-980-6933
Mailing address:
  • Phone: 586-217-1494
  • Fax: 586-980-6933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberW5C4F8R8
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: