=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780391284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAVON COOKE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2022
-----------------------------------------------------
Last Update Date | 01/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 168 WILLIAMS ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23704-1835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-759-1619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1021 EDEN WAY NORTH PMB 339 STE 118
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-759-1619
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 202K00000X
-----------------------------------------------------
Taxonomy Name | Phlebology Physician
-----------------------------------------------------
License Number | 43990-167-465-8163
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2083T0002X
-----------------------------------------------------
Taxonomy Name | Medical Toxicology (Preventive Medicine) Physician
-----------------------------------------------------
License Number | 43990-167-465-8163
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------