Provider Demographics
NPI:1861565327
Name:MCCORMICK, COLEEN R (CNP)
Entity type:Individual
Prefix:MS
First Name:COLEEN
Middle Name:R
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:COLEEN
Other - Middle Name:R
Other - Last Name:POPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:544 PATTERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-2514
Mailing Address - Country:US
Mailing Address - Phone:513-896-9595
Mailing Address - Fax:513-896-4171
Practice Address - Street 1:544 PATTERSON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2514
Practice Address - Country:US
Practice Address - Phone:513-896-9595
Practice Address - Fax:513-896-4171
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08027363LP2300X
OHAPRN.CNP.08027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2661123Medicaid
OHQ28392Medicare UPIN
OH2661123Medicaid