Provider Demographics
NPI:1245849249
Name:MCCORMICK, TRESA DEE (APRN)
Entity type:Individual
Prefix:MRS
First Name:TRESA
Middle Name:DEE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TRESA
Other - Middle Name:DEE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34709 9TH AVE S STE B500
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6789
Mailing Address - Country:US
Mailing Address - Phone:253-944-6950
Mailing Address - Fax:253-661-8603
Practice Address - Street 1:34709 9TH AVE S STE B500
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6789
Practice Address - Country:US
Practice Address - Phone:253-944-6950
Practice Address - Fax:253-661-8603
Is Sole Proprietor?:No
Enumeration Date:2020-07-26
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61035964367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2164932Medicaid