Provider Demographics
NPI:1841276565
Name:MCCORMACK, SANDRA LEE (APRN)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LEE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 GREAT HILL WAY
Mailing Address - Street 2:
Mailing Address - City:ELIOT
Mailing Address - State:ME
Mailing Address - Zip Code:03903-1618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 GRIFFIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7113
Practice Address - Country:US
Practice Address - Phone:603-436-7897
Practice Address - Fax:603-433-1985
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02004921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30346941Medicaid
NH3083632Medicaid
NHP01011563OtherRAILROAD MEDICARE
NH30346941Medicaid