Healthcare Provider Details

I. General information

NPI: 1396047205
Provider Name (Legal Business Name): JOAN MACCORMACK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 HIGHLAND AVE 2ND FL
SOMERVILLE MA
02143-1495
US

IV. Provider business mailing address

236 HIGHLAND AVE 2ND FL
SOMERVILLE MA
02143-1495
US

V. Phone/Fax

Practice location:
  • Phone: 617-591-4332
  • Fax:
Mailing address:
  • Phone: 617-591-4332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License NumberRN187052
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: