MEDICARE: MRS. STACY MCCOURT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209.015874	IL

General Provider Information

NPI Number	:	1013422799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACY MCCOURT NP

Provider Business Mailing Address
First Line	:	1641 N NORTH PARK AVE APT 2R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-5788
Country	:	US
Telephone Number	:	734-716-0235
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 W ARMITAGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4103
Country	:	US
Telephone Number	:	773-529-5277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2017
Last Update Date	:	12/04/2017

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