Provider Demographics
NPI:1629120217
Name:MCCORMACK, ELIZABETH E (ARNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:E
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 W JORDAN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1736
Mailing Address - Country:US
Mailing Address - Phone:850-434-0077
Mailing Address - Fax:850-434-0220
Practice Address - Street 1:14 W JORDAN ST
Practice Address - Street 2:SUITE C
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1736
Practice Address - Country:US
Practice Address - Phone:850-434-0077
Practice Address - Fax:850-434-0220
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2013-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3151122363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY107YOtherFLORIDA BLUE
FL306069100Medicaid
FLY107YOtherFLORIDA BLUE