Healthcare Provider Details

I. General information

NPI: 1942264718
Provider Name (Legal Business Name): SANDRA L MCCORMICK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA L POTTER

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19550 E 39TH ST S SUITE 245
INDEPENDENCE MO
64057-2358
US

IV. Provider business mailing address

19550 E 39TH ST S SUITE 245
INDEPENDENCE MO
64057-2358
US

V. Phone/Fax

Practice location:
  • Phone: 816-373-0655
  • Fax: 816-478-6374
Mailing address:
  • Phone: 816-373-0655
  • Fax: 816-478-6374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number069917
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: