MEDICARE: STACY MCCORMICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN389497	OH

General Provider Information

NPI Number	:	1154783702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY MCCORMICK

Provider Business Mailing Address
First Line	:	141 KENNETH AVE
Second Line	:
City	:	VANDALIA
State	:	OH
Zip	:	45377-3005
Country	:	US
Telephone Number	:	937-902-8617
Fax Number	:

Provider Business Practice Location Address
First Line	:	2261 PHILADELPHIA DR
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45406-1814
Country	:	US
Telephone Number	:	937-734-4141
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	03/23/2016

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Directions to “ STACY MCCORMICK ” Practice Location

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