Healthcare Provider Details

I. General information

NPI: 1124492103
Provider Name (Legal Business Name): KIRSTEN MCCORMACK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIRSTEN KOWALSKI FNP-C

II. Dates (important events)

Enumeration Date: 11/13/2015
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HOMESTEAD AVE
WHEELING WV
26003-6638
US

IV. Provider business mailing address

24 HOMESTEAD AVE
WHEELING WV
26003-6638
US

V. Phone/Fax

Practice location:
  • Phone: 304-232-1020
  • Fax:
Mailing address:
  • Phone: 304-232-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA. 18067-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN80991-NP-C
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: