Provider Demographics
NPI:1063696425
Name:COOK, GINA MARIE (FNP-BC)
Entity type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MARIE
Last Name:COOK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-315-7910
Mailing Address - Fax:289-722-6113
Practice Address - Street 1:601 W RIVERSIDE DR STE 4
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:AZ
Practice Address - Zip Code:85344-5119
Practice Address - Country:US
Practice Address - Phone:928-256-4110
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR28493363LF0000X
AZ247215363LF0000X, 363LP2300X
NDR28492363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ247215OtherCERTIFIED NURSE PRACTITIONER LICENSE
ND19956Medicaid