Provider Demographics
NPI:1851851190
Name:MCCORMICK, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 CR 1240
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:TX
Mailing Address - Zip Code:77664
Mailing Address - Country:US
Mailing Address - Phone:409-200-4406
Mailing Address - Fax:
Practice Address - Street 1:877 CR 1240
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:TX
Practice Address - Zip Code:77664
Practice Address - Country:US
Practice Address - Phone:409-200-4406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233772164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse