Healthcare Provider Details

I. General information

NPI: 1821004458
Provider Name (Legal Business Name): CAROL ANNE MCCORMICK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 MISSION ST
SAN MARINO CA
91108
US

IV. Provider business mailing address

4525 E ATHERTON ST
LONG BEACH CA
90815-3700
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-8989
  • Fax: 626-403-8969
Mailing address:
  • Phone: 562-961-0155
  • Fax: 562-961-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number23089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: