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General NPI Number Information
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NPI Number | 1215266713
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Entity Type | Individual
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Provider Name | MARY YVONNE MCCORMICK RD, CDE
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Gender | Female
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Dates
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Enumeration Date | 12/11/2009
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Last Update Date | 12/11/2009
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Provider Practice Location Address
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Address Line | 820 PRUDENTIAL DR SUITE 416
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8210
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Country | US
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Telephone | 904-202-1152
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Fax | 904-202-1152
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Provider Business Mailing Address
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Address Line | 820 PRUDENTIAL DR STE 416
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8206
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Country | US
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Telephone | 904-202-1152
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Fax | 904-202-2462
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND 1658
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License Number State | FL
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