Healthcare Provider Details

I. General information

NPI: 1790240885
Provider Name (Legal Business Name): TERESA ANN MCCORMACK RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA ANN MCCORMACK RN

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4443 30TH ST STE 205
SAN DIEGO CA
92116-4291
US

IV. Provider business mailing address

9728 MARILLA DR UNIT 205
LAKESIDE CA
92040-2853
US

V. Phone/Fax

Practice location:
  • Phone: 619-312-1832
  • Fax:
Mailing address:
  • Phone: 858-216-6257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number784994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: