Healthcare Provider Details

I. General information

NPI: 1285614230
Provider Name (Legal Business Name): CAROLYN JO MCCORMIES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 W 16TH ST
SAFFORD AZ
85546-4081
US

IV. Provider business mailing address

PO BOX 367
CENTRAL AZ
85531-0367
US

V. Phone/Fax

Practice location:
  • Phone: 928-428-3122
  • Fax:
Mailing address:
  • Phone: 928-428-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP1951
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: