Provider Demographics
NPI:1003455361
Name:MCCORMACK, ASHLEY ANDERSON
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANDERSON
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3810 CENTRAL PIKE
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-3494
Mailing Address - Country:US
Mailing Address - Phone:931-967-9393
Mailing Address - Fax:
Practice Address - Street 1:1670 W MAIN ST STE 140
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-1345
Practice Address - Country:US
Practice Address - Phone:615-994-8201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-03
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26970363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner