Provider Demographics
NPI:1306137898
Name:MCCORMICK, ELIZABETH ANN (LPN)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:GRUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:CONSTABLE
Mailing Address - State:NY
Mailing Address - Zip Code:12926
Mailing Address - Country:US
Mailing Address - Phone:518-521-0916
Mailing Address - Fax:
Practice Address - Street 1:15918 STATE RD 30
Practice Address - Street 2:
Practice Address - City:CONSTABLE
Practice Address - State:NY
Practice Address - Zip Code:12926
Practice Address - Country:US
Practice Address - Phone:518-521-0916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118743-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse