Provider Demographics
NPI:1215102462
Name:MCCORMICK, GRETA ANITA (MSN, APRN, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:GRETA
Middle Name:ANITA
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:MSN, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 N HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6516
Mailing Address - Country:US
Mailing Address - Phone:318-676-5111
Mailing Address - Fax:
Practice Address - Street 1:151 FREESTATE BLVD STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6549
Practice Address - Country:US
Practice Address - Phone:318-226-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA227483363LP0808X
LA0056725163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health