Healthcare Provider Details

I. General information

NPI: 1730656422
Provider Name (Legal Business Name): EMILY L MCCORMAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY MCCOLLUM PMHNP

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2352C HIGHWAY 15 N
PONTOTOC MS
38863-8998
US

IV. Provider business mailing address

2352C HIGHWAY 15 N
PONTOTOC MS
38863-8998
US

V. Phone/Fax

Practice location:
  • Phone: 662-597-7977
  • Fax: 662-597-7977
Mailing address:
  • Phone: 662-205-0305
  • Fax: 662-200-9053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number903001
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number903001
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: