Healthcare Provider Details

I. General information

NPI: 1609280254
Provider Name (Legal Business Name): CONNIE HODGES - MCCORMICK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE HODGES NURSE

II. Dates (important events)

Enumeration Date: 06/11/2014
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-5062
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-5062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number53-75726-061
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number75726
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: