Provider Demographics
NPI:1871465633
Name:MCCORMACK, KRISTA ANNE
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:ANNE
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 1:107 PENNELLS CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANNON
Mailing Address - State:PA
Mailing Address - Zip Code:17020-9665
Mailing Address - Country:US
Mailing Address - Phone:717-961-1195
Mailing Address - Fax:
Practice Address - Street 1:107 PENNELLS CHURCH RD
Practice Address - Street 2:
Practice Address - City:DUNCANNON
Practice Address - State:PA
Practice Address - Zip Code:17020-9665
Practice Address - Country:US
Practice Address - Phone:717-961-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer