Provider Demographics
NPI:1518211333
Name:MCCORMICK, STEPHANIE ELLEN (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 S 144TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5225
Mailing Address - Country:US
Mailing Address - Phone:402-778-5200
Mailing Address - Fax:402-778-5216
Practice Address - Street 1:2727 S 144TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5225
Practice Address - Country:US
Practice Address - Phone:402-778-5200
Practice Address - Fax:402-778-5216
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07683731Medicaid
CO0000032OtherSTATE OF COLORADO LICENSE
CO266856YM8SMedicare PIN