Provider Demographics
NPI:1780355016
Name:MCCORMICK, SKYLAR (APRN)
Entity type:Individual
Prefix:MS
First Name:SKYLAR
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SKYLAR
Other - Middle Name:
Other - Last Name:EDMISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-998-0888
Practice Address - Fax:618-993-1808
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.024058363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health