Provider Demographics
NPI:1053713867
Name:COOK, KELLY (RT,CT,RDMS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COOK
Suffix:
Gender:F
Credentials:RT,CT,RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4014 CALION HWY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-9447
Mailing Address - Country:US
Mailing Address - Phone:870-310-1757
Mailing Address - Fax:
Practice Address - Street 1:706 W GROVE ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4416
Practice Address - Country:US
Practice Address - Phone:870-310-1757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR592962471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography