=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831602341
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESIREE DAWN COOK CPNP-PC, PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2017
-----------------------------------------------------
Last Update Date | 11/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3750 E. COUNTRY FIELD CIRCLE SUITE C
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-357-2955
-----------------------------------------------------
Fax | 907-357-9348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3505 E MERIDIAN PARK LOOP STE 200
-----------------------------------------------------
City | WASILLA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99654-7242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-357-4400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 126978
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 2023001598
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------