Healthcare Provider Details

I. General information

NPI: 1053982900
Provider Name (Legal Business Name): KAYLA MCCORMICK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 ALBERTA DR
WINONA MS
38967-1597
US

IV. Provider business mailing address

2385 COUNTY ROAD 213
GRENADA MS
38901-6634
US

V. Phone/Fax

Practice location:
  • Phone: 662-283-3655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number904725
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: