Provider Demographics
NPI:1558512558
Name:WIGINTON-MCCORMICK, LARA KATHLEEN (CNM)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:KATHLEEN
Last Name:WIGINTON-MCCORMICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:KATHLEEN
Other - Last Name:MCCORMICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1025 PENNOCK PL
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3257
Mailing Address - Country:US
Mailing Address - Phone:970-495-8800
Mailing Address - Fax:970-495-8820
Practice Address - Street 1:1025 PENNOCK PL
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-3257
Practice Address - Country:US
Practice Address - Phone:970-495-8800
Practice Address - Fax:970-495-8820
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990222363L00000X
CO190225163W00000X
COAPN.0006038-CNM367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO40925722Medicaid
COCOA108072Medicare PIN