Provider Demographics
NPI:1821004458
Name:MCCORMICK, CAROL ANNE (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 E ATHERTON ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-3700
Mailing Address - Country:US
Mailing Address - Phone:562-961-0155
Mailing Address - Fax:562-961-0161
Practice Address - Street 1:2400 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN MARINO
Practice Address - State:CA
Practice Address - Zip Code:91108
Practice Address - Country:US
Practice Address - Phone:626-403-8989
Practice Address - Fax:626-403-8969
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23089363LP0808X
OHNP-08883363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2771086Medicaid
OH2771086Medicaid
OH20841Medicare PIN
CAHI453ZMedicare PIN
OHQ70719Medicare PIN