MEDICARE: MS. THERESA J. MCCORMICK APRN

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	163WP0809X	Adult Psychiatric/Mental Health Registered Nurse	216295-9938	UT

General Provider Information

NPI Number	:	1164490520
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THERESA J. MCCORMICK APRN

Provider Business Mailing Address
First Line	:	507 ANDERSON AVE
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84123-5722
Country	:	US
Telephone Number	:	801-685-2380
Fax Number	:	801-281-1709

Provider Business Practice Location Address
First Line	:	1399 S 700 E
Second Line	:	SUITE F-14
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2149
Country	:	US
Telephone Number	:	801-530-3725
Fax Number	:	801-281-1709

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

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	07/09/2007

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