Provider Demographics
NPI:1295281806
Name:MCCORMICK, SHANNON GREEN (APRN, CFCP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:GREEN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:APRN, CFCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 S CLAIBORNE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-5010
Mailing Address - Country:US
Mailing Address - Phone:504-496-0212
Mailing Address - Fax:
Practice Address - Street 1:4612 S. CLAIBORNE AVE.
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125
Practice Address - Country:US
Practice Address - Phone:504-496-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA71607163WW0101X
LA204160363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295281806OtherCENTERS FOR MEDICARE AND MEDICAID SERVICES IDENTITY & ACCESS (I&A) SYSTEM