Provider Demographics
NPI:1487271409
Name:COOK, WENDY CARA
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:CARA
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:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0461
Mailing Address - Country:US
Mailing Address - Phone:605-488-0146
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH ST AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDP011428164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse