Provider Demographics
NPI:1225267511
Name:MCCORMACK, MARY BRIDGET (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BRIDGET
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:BRIDGET
Other - Last Name:MCDONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:208 ROXBURY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11697-1406
Mailing Address - Country:US
Mailing Address - Phone:718-945-7166
Mailing Address - Fax:
Practice Address - Street 1:208 ROXBURY AVE
Practice Address - Street 2:
Practice Address - City:ROCKAWAY POINT
Practice Address - State:NY
Practice Address - Zip Code:11697-1406
Practice Address - Country:US
Practice Address - Phone:718-945-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3359041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily