Provider Demographics
NPI:1528609989
Name:COOK, LARTAVIA
Entity type:Individual
Prefix:
First Name:LARTAVIA
Middle Name:
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 1:6805 LANCER LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-6033
Mailing Address - Country:US
Mailing Address - Phone:405-619-8577
Mailing Address - Fax:
Practice Address - Street 1:6805 LANCER LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-6033
Practice Address - Country:US
Practice Address - Phone:405-619-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No171M00000XOther Service ProvidersCase Manager/Care Coordinator