Provider Demographics
NPI:1952444671
Name:MCCORMICK, MARTHA MICHELLE
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:MICHELLE
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 1:24 HOLLIMAN LN
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37030-2315
Mailing Address - Country:US
Mailing Address - Phone:615-735-0242
Mailing Address - Fax:615-735-8250
Practice Address - Street 1:24 HOLLIMAN LN
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030-2315
Practice Address - Country:US
Practice Address - Phone:615-735-0242
Practice Address - Fax:615-735-8250
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN376K00000XOtherNURSE AIDE