Provider Demographics
NPI:1962759696
Name:COOK - JOHNSON, NICOLE SHARAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SHARAE
Last Name:COOK - JOHNSON
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 1:5608 NW 112TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-3510
Mailing Address - Country:US
Mailing Address - Phone:405-367-7306
Mailing Address - Fax:
Practice Address - Street 1:6701 W WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-5492
Practice Address - Country:US
Practice Address - Phone:405-535-8838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health