Healthcare Provider Details

I. General information

NPI: 1225267511
Provider Name (Legal Business Name): MARY BRIDGET MCCORMACK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY BRIDGET MCDONNELL FNP

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 ROXBURY AVE
ROCKAWAY POINT NY
11697-1406
US

IV. Provider business mailing address

208 ROXBURY AVE
ROCKAWAY POINT NY
11697-1406
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7166
  • Fax:
Mailing address:
  • Phone: 718-945-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF3359041
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: