Provider Demographics
NPI:1639278690
Name:MCCORRISON, MABEL (FNP)
Entity Type:Individual
Prefix:
First Name:MABEL
Middle Name:
Last Name:MCCORRISON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 625
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5516
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:22890 VIRGIL GOODE HWY
Practice Address - Street 2:
Practice Address - City:BOONES MILL
Practice Address - State:VA
Practice Address - Zip Code:24065
Practice Address - Country:US
Practice Address - Phone:540-344-5511
Practice Address - Fax:540-344-3174
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166899363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1639278690Medicaid
VAPENDINGMedicaid
VAPENDINGMedicaid
VA1639278690Medicaid