Provider Demographics
NPI:1013960236
Name:MCCORMICK, MARY ELLEN (CRNP)
Entity Type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUNDY STREET
Mailing Address - Street 2:MAC IV BUILDING
Mailing Address - City:WILKES-BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6380
Mailing Address - Country:US
Mailing Address - Phone:570-824-0930
Mailing Address - Fax:570-824-7755
Practice Address - Street 1:150 MUNDY ST
Practice Address - Street 2:MAC IV BUILDING
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6830
Practice Address - Country:US
Practice Address - Phone:570-824-0930
Practice Address - Fax:570-824-7755
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP003894C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50076332OtherCAPITAL BLUE CROSS
PAS64281Medicare UPIN
PA019287J67Medicare PIN