Provider Demographics
NPI:1740626563
Name:MCCOURT, JOAN M (ANP)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:M
Last Name:MCCOURT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 CLARKSON RD
Mailing Address - Street 2:
Mailing Address - City:ELLISVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2219
Mailing Address - Country:US
Mailing Address - Phone:636-256-8644
Mailing Address - Fax:
Practice Address - Street 1:233 CLARKSON RD
Practice Address - Street 2:
Practice Address - City:ELLISVILLE
Practice Address - State:MO
Practice Address - Zip Code:63011-2219
Practice Address - Country:US
Practice Address - Phone:636-256-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO069564363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO069564OtherLICENSE