Healthcare Provider Details

I. General information

NPI: 1053721068
Provider Name (Legal Business Name): AMY COKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1417 PARKVIEW DR
ELIZABETH CITY NC
27909-6533
US

IV. Provider business mailing address

1417 PARKVIEW DR
ELIZABETH CITY NC
27909-6533
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-4044
  • Fax: 252-337-7928
Mailing address:
  • Phone: 252-338-4044
  • Fax: 252-337-7928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number12153
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: