Provider Demographics
NPI:1740694959
Name:LAI-MCCORMACK, JENNIFER (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LAI-MCCORMACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:R
Other - Last Name:LAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:6006 43RD AVE
Mailing Address - Street 2:1D
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-4977
Mailing Address - Country:US
Mailing Address - Phone:917-558-6832
Mailing Address - Fax:
Practice Address - Street 1:6006 43RD AVE
Practice Address - Street 2:1D
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-4977
Practice Address - Country:US
Practice Address - Phone:917-558-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY589522-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered