Provider Demographics
NPI:1255494902
Name:MCCORMICK, DONNA SUZANNE (NP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:SUZANNE
Last Name:MCCORMICK
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 1:9221 MIDDLEBROOK PIKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37931-4764
Mailing Address - Country:US
Mailing Address - Phone:865-539-2873
Mailing Address - Fax:865-539-2969
Practice Address - Street 1:9221 MIDDLEBROOK PIKE
Practice Address - Street 2:SUITE 102
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37931-4764
Practice Address - Country:US
Practice Address - Phone:865-539-2873
Practice Address - Fax:865-539-2969
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN87767363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNS86635Medicare UPIN
TN3344571Medicare ID - Type Unspecified