Provider Demographics
NPI:1528276417
Name:COOKE, KELLY JO (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JO
Last Name:COOKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:DENIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVE STE 508
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-5071
Mailing Address - Country:US
Mailing Address - Phone:262-928-4898
Mailing Address - Fax:
Practice Address - Street 1:721 AMERICAN AVE STE 508
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5071
Practice Address - Country:US
Practice Address - Phone:262-928-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105206207RH0002X
WI61139207RH0002X
TXBP20022320207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I22527Medicare UPIN
WI68375Medicare PIN