Provider Demographics
NPI:1750463766
Name:MCCORMACK, LEAH R (PNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:R
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-4410
Mailing Address - Country:US
Mailing Address - Phone:727-372-6760
Mailing Address - Fax:727-372-6808
Practice Address - Street 1:2137 LITTLE RD
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-4410
Practice Address - Country:US
Practice Address - Phone:727-372-6760
Practice Address - Fax:727-372-6808
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3817971363L00000X
NC300266363L00000X
PASP010297363L00000X
FLARNP9351470363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner