Provider Demographics
NPI:1285110700
Name:COOK, MIRANDA NICHOLE (COTA, L)
Entity type:Individual
Prefix:MS
First Name:MIRANDA
Middle Name:NICHOLE
Last Name:COOK
Suffix:
Gender:F
Credentials:COTA, L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803A INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-3151
Mailing Address - Country:US
Mailing Address - Phone:270-875-5958
Mailing Address - Fax:
Practice Address - Street 1:803A INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-3151
Practice Address - Country:US
Practice Address - Phone:270-875-5958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY401657224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant