Healthcare Provider Details

I. General information

NPI: 1649155565
Provider Name (Legal Business Name): CECILIA ELESE COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 GOODMAN RD E STE 200
SOUTHAVEN MS
38671-8313
US

IV. Provider business mailing address

PO BOX 616
NEW ALBANY MS
38652-0616
US

V. Phone/Fax

Practice location:
  • Phone: 662-384-6949
  • Fax:
Mailing address:
  • Phone: 662-266-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907536
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: