Provider Demographics
NPI:1962831172
Name:MCCORMICK, SHELLEY A (STNA)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:A
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E STEWART AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:OH
Mailing Address - Zip Code:43845-1047
Mailing Address - Country:US
Mailing Address - Phone:740-545-6821
Mailing Address - Fax:
Practice Address - Street 1:112 E STEWART AVE
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:OH
Practice Address - Zip Code:43845-1047
Practice Address - Country:US
Practice Address - Phone:740-545-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X
OH401331591211376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0078766Medicaid
OH1601145OtherDODD