Provider Demographics
NPI:1063074284
Name:COOK, TIA LATOSHA
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:LATOSHA
Last Name:COOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2816 WALNUT HILL ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2816 WALNUT HILL ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-1503
Practice Address - Country:US
Practice Address - Phone:800-484-3307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health