Provider Demographics
NPI:1356945000
Name:MCCORMICK- NELSON, MANDISA FAYOLA (ASSISTIVE CARE PRO)
Entity type:Individual
Prefix:
First Name:MANDISA
Middle Name:FAYOLA
Last Name:MCCORMICK- NELSON
Suffix:
Gender:F
Credentials:ASSISTIVE CARE PRO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 BEECHER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-2306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1534 BEECHER DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-2306
Practice Address - Country:US
Practice Address - Phone:131-422-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747A0650X
MO251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty