Provider Demographics
NPI:1144906082
Name:COOK, ABBY LEE (PA)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:LEE
Last Name:COOK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-8777
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3585
Practice Address - Country:US
Practice Address - Phone:321-434-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118717363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW788OtherMEDICARE HF
FL122145300Medicaid
FLS3420OtherMEDICARE HFPSI