Provider Demographics
NPI:1104830843
Name:MERCER, KATHLEEN MCCORMICK (APN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MCCORMICK
Last Name:MERCER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:B
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:611 S DUPONT HIGHWAY
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4507
Practice Address - Country:US
Practice Address - Phone:302-741-2123
Practice Address - Fax:302-741-2007
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELJ0000119363LP0200X
DEL10022291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD443301700Medicaid
DELJ0000119OtherN.P. PROFESSIONAL LICENSE
DELJ0000119OtherN.P. PROFESSIONAL LICENSE