=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548827066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELONIE ANN COOK APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2019
-----------------------------------------------------
Last Update Date | 05/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1407 JENNIFER ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-2091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-9611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 JENNIFER ST
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-2091
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-466-9611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | A005489
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------