Healthcare Provider Details

I. General information

NPI: 1104830843
Provider Name (Legal Business Name): KATHLEEN MCCORMICK MERCER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN B MCCORMICK

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 S DUPONT HIGHWAY
DOVER DE
19901-4507
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-741-2123
  • Fax: 302-741-2007
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberLJ0000119
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberL10022291
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: