Provider Demographics
NPI:1053910752
Name:COOKE, NICOLE MARIA (PMHNP-BC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIA
Last Name:COOKE
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5964 US HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8694
Mailing Address - Country:US
Mailing Address - Phone:386-963-6530
Mailing Address - Fax:
Practice Address - Street 1:5964 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-8694
Practice Address - Country:US
Practice Address - Phone:631-388-3933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9435338390200000X
FL11013322363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program