=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598294167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY MARIE MCCORMACK APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2017
-----------------------------------------------------
Last Update Date | 11/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 BOULDER POINT DR STE 1
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03264-3170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-536-4000
-----------------------------------------------------
Fax | 603-536-4001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 FAIRGROUNDS RD
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03264-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-953-3778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 062717-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 062717-23
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------