Provider Demographics
NPI:1336647031
Name:MCCORMICK, TERESA ELEANOR
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ELEANOR
Last Name:MCCORMICK
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 1:4203 TORRAZZO WAY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-5444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4203 TORRAZZO WAY
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-5444
Practice Address - Country:US
Practice Address - Phone:720-355-9169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-28
Last Update Date:2018-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN687288164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse