Healthcare Provider Details

I. General information

NPI: 1861565327
Provider Name (Legal Business Name): COLEEN R MCCORMICK CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLEEN R POPP NP

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 PATTERSON BLVD
FAIRFIELD OH
45014-2514
US

IV. Provider business mailing address

544 PATTERSON BLVD
FAIRFIELD OH
45014-2514
US

V. Phone/Fax

Practice location:
  • Phone: 513-896-9595
  • Fax: 513-896-4171
Mailing address:
  • Phone: 513-896-9595
  • Fax: 513-896-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.08027
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number08027
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: