Provider Demographics
NPI:1568624757
Name:MCCORKLE, PATEICIA ANN
Entity Type:Individual
Prefix:MS
First Name:PATEICIA
Middle Name:ANN
Last Name:MCCORKLE
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 1:7185 SCOBELL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1502
Mailing Address - Country:US
Mailing Address - Phone:225-935-2208
Mailing Address - Fax:225-935-2209
Practice Address - Street 1:7262 POINSETTIA DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-1861
Practice Address - Country:US
Practice Address - Phone:225-288-6931
Practice Address - Fax:225-935-2209
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-28
Last Update Date:2008-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LASIL20075251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA24Medicaid
LA89Medicaid
LA03Medicaid
LA82Medicaid