Healthcare Provider Details

I. General information

NPI: 1487092946
Provider Name (Legal Business Name): LESLIE RACHEL MCCORMACK CNM APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2013
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5302 VILLAGE PKWY SUITE 3
ROGERS AR
72758-8102
US

IV. Provider business mailing address

5302 VILLAGE PKWY SUITE 3
ROGERS AR
72758-8102
US

V. Phone/Fax

Practice location:
  • Phone: 479-372-4560
  • Fax: 501-712-4530
Mailing address:
  • Phone: 479-372-4560
  • Fax: 501-712-4530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberM002119
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: