Healthcare Provider Details

I. General information

NPI: 1164490520
Provider Name (Legal Business Name): THERESA J. MCCORMICK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 S 700 E SUITE F-14
SALT LAKE CITY UT
84105-2149
US

IV. Provider business mailing address

507 ANDERSON AVE
MURRAY UT
84123-5722
US

V. Phone/Fax

Practice location:
  • Phone: 801-530-3725
  • Fax: 801-281-1709
Mailing address:
  • Phone: 801-685-2380
  • Fax: 801-281-1709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number216295-9938
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: