Provider Demographics
NPI:1215644489
Name:MCCORMICK, AYESHA MONAY (AGNP-C)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:MONAY
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2611 FOREST DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2371
Mailing Address - Country:US
Mailing Address - Phone:037-793-2638
Mailing Address - Fax:803-779-3207
Practice Address - Street 1:2611 FOREST DR STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2371
Practice Address - Country:US
Practice Address - Phone:803-779-3263
Practice Address - Fax:803-779-3207
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN.29792363LG0600X
CA95074286163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC319785OtherNC BOARD OF NURSING
CA95074286OtherCA BOARD OF NURSING