Provider Demographics
NPI:1851062012
Name:COOKE, EBONY JOY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:JOY
Last Name:COOKE
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 1:2061 EXPERIMENT STATION RD
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-5328
Mailing Address - Country:US
Mailing Address - Phone:919-559-6756
Mailing Address - Fax:
Practice Address - Street 1:2061 EXPERIMENT STATION RD STE 505
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-5327
Practice Address - Country:US
Practice Address - Phone:706-310-0324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA11485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant