Healthcare Provider Details

I. General information

NPI: 1538685581
Provider Name (Legal Business Name): KASEY MCCORMICK NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

500 N LAKE SHORE DR APT 3706
CHICAGO IL
60611-5157
US

V. Phone/Fax

Practice location:
  • Phone: 217-414-7945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number209-016359
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: