Provider Demographics
NPI:1881992444
Name:MCCORMACK, IRENE LOFTUS (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:LOFTUS
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:MA
Mailing Address - Zip Code:01834
Mailing Address - Country:US
Mailing Address - Phone:978-372-1407
Mailing Address - Fax:
Practice Address - Street 1:97 KING ST
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:MA
Practice Address - Zip Code:01834-1811
Practice Address - Country:US
Practice Address - Phone:978-372-1407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-07
Last Update Date:2011-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAPPLYING171100000X
MARN94644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171100000XOther Service ProvidersAcupuncturist