MEDICARE: MISS IVY MITCHELL COOKS B.S., NA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide
2	376K00000X	Nurse's Aide

General Provider Information

NPI Number	:	1093952491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS IVY MITCHELL COOKS B.S., NA

Provider Business Mailing Address
First Line	:	800 BOULDER SPRINGS DR
Second Line	:	#B2
City	:	RICHMOND
State	:	VA
Zip	:	23225-5535
Country	:	US
Telephone Number	:	804-617-1762
Fax Number	:	804-447-1449

Provider Business Practice Location Address
First Line	:	800 BOULDER SPRINGS DR
Second Line	:	#B2
City	:	RICHMOND
State	:	VA
Zip	:	23225-5535
Country	:	US
Telephone Number	:	804-617-1762
Fax Number	:	804-447-1449

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2009
Last Update Date	:	01/07/2009

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