Provider Demographics
NPI:1568851285
Name:MCCORMICK, SHELBY
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:MCCORMICK
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 1:4710 GRISWOLD RD
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MI
Mailing Address - Zip Code:48074-2102
Mailing Address - Country:US
Mailing Address - Phone:810-956-7678
Mailing Address - Fax:
Practice Address - Street 1:4710 GRISWOLD RD
Practice Address - Street 2:
Practice Address - City:KIMBALL
Practice Address - State:MI
Practice Address - Zip Code:48074-2102
Practice Address - Country:US
Practice Address - Phone:810-956-7678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-19
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114453164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse