Provider Demographics
NPI:1164490520
Name:MCCORMICK, THERESA J (APRN)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:J
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5722
Mailing Address - Country:US
Mailing Address - Phone:801-685-2380
Mailing Address - Fax:801-281-1709
Practice Address - Street 1:1399 S 700 E
Practice Address - Street 2:SUITE F-14
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2149
Practice Address - Country:US
Practice Address - Phone:801-530-3725
Practice Address - Fax:801-281-1709
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT216295-9938163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ15445Medicare UPIN