Basic Information
| Provider Information | |||||||||
| NPI: | 1538231915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCORMICK | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHIBAN | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003944445 | ||||||||
| FaxNumber: | 7066501034 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 E MARSHALL STREET | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193804412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104315472 | ||||||||
| FaxNumber: | 6104302914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN523431L | PA | N | Nursing Service Providers | Registered Nurse | 172A00000X | 23814069 | PA | N | Other Service Providers | Driver | 363L00000X | SP009046 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.