Healthcare Provider Details

I. General information

NPI: 1114292992
Provider Name (Legal Business Name): RENEE ROWE MCCORMACK ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HOSPITAL DR
CRESTVIEW FL
32539-7355
US

IV. Provider business mailing address

PO BOX 1522
SANTA ROSA BEACH FL
32459-1522
US

V. Phone/Fax

Practice location:
  • Phone: 850-687-0887
  • Fax:
Mailing address:
  • Phone: 614-673-6737
  • Fax: 850-509-1764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9230927
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9230927
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: