Provider Demographics
NPI:1982348355
Name:MCCORMACK, KRISTEN MICHELLE
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:MCCORMACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PERRY HILL RD STE 575
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-3630
Mailing Address - Country:US
Mailing Address - Phone:334-546-5978
Mailing Address - Fax:
Practice Address - Street 1:616 CHAFFEE ST
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2809
Practice Address - Country:US
Practice Address - Phone:256-362-4197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-141418163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse