MEDICARE: AMANDA MCCORMICK AGNP-C

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	363L00000X	Nurse Practitioner	4704292297	MI

General Provider Information

NPI Number	:	1295333938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MCCORMICK AGNP-C

Provider Business Mailing Address
First Line	:	624 CHERRY ST SE APT 5
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4778
Country	:	US
Telephone Number	:	269-718-8612
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 CHERRY ST SE APT 5
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-4778
Country	:	US
Telephone Number	:	269-718-8612
Fax Number	:

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

Provider Enumeration Date	:	10/14/2020
Last Update Date	:	03/10/2026

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