Provider Demographics
NPI:1558366336
Name:MCCORMICK, SUSAN SAMANTHA (ARNP, CNM)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:SAMANTHA
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 S TUTTLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-3114
Mailing Address - Country:US
Mailing Address - Phone:941-330-8885
Mailing Address - Fax:239-906-8774
Practice Address - Street 1:1900 S TUTTLE AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3114
Practice Address - Country:US
Practice Address - Phone:941-330-8885
Practice Address - Fax:941-906-8774
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9214701363LX0001X
FLARPN9214701367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3064565 00Medicaid