Provider Demographics
NPI:1689658874
Name:MCCORMICK, URSULA SUE (CNS)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:SUE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:URSULA
Other - Middle Name:SUE
Other - Last Name:MEYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2353
Practice Address - Country:US
Practice Address - Phone:812-339-1691
Practice Address - Fax:812-337-2438
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000019A364SP0807X, 364SP0808X
IN28114646163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No364SP0807XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Adolescent
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000374550OtherANTHEM
IN200110210AMedicaid
IN200110210AMedicaid
IN601530AMedicare ID - Type Unspecified