Provider Demographics
NPI:1447611868
Name:MCCORMACK, THERESA (PNP)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 WATERSIDE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875-1265
Mailing Address - Country:US
Mailing Address - Phone:804-520-0002
Mailing Address - Fax:804-520-2259
Practice Address - Street 1:2035 WATERSIDE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875-1265
Practice Address - Country:US
Practice Address - Phone:804-520-0002
Practice Address - Fax:804-520-2259
Is Sole Proprietor?:No
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165150363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics