Provider Demographics
NPI:1013422799
Name:MCCOURT, STACY (NP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:MCCOURT
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 1:1641 N NORTH PARK AVE APT 2R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-5788
Mailing Address - Country:US
Mailing Address - Phone:734-716-0235
Mailing Address - Fax:
Practice Address - Street 1:1133 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4103
Practice Address - Country:US
Practice Address - Phone:773-529-5277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015874363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily