Healthcare Provider Details

I. General information

NPI: 1013545664
Provider Name (Legal Business Name): JOHANNA YADIRA COOK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1602
US

IV. Provider business mailing address

1364 W QUEEN ST
HAMPTON VA
23669-3842
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7111
  • Fax:
Mailing address:
  • Phone: 757-232-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number0001224821
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11008593
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: