Healthcare Provider Details

I. General information

NPI: 1356903637
Provider Name (Legal Business Name): CARRIE MCCORMICK APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE COOK

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 04/26/2024
Certification Date: 04/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 HEDLEY RD
SPRINGFIELD IL
62711-6248
US

IV. Provider business mailing address

3225 HEDLEY RD
SPRINGFIELD IL
62711-6248
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-7300
  • Fax: 217-726-5989
Mailing address:
  • Phone: 217-726-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.385417
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209020123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: