Provider Demographics
NPI:1588990527
Name:MCCORMICK, JERILYN MICHELLE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JERILYN
Middle Name:MICHELLE
Last Name:MCCORMICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-7694
Mailing Address - Country:US
Mailing Address - Phone:678-312-1000
Mailing Address - Fax:678-312-3282
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-7694
Practice Address - Country:US
Practice Address - Phone:678-312-1000
Practice Address - Fax:678-312-3282
Is Sole Proprietor?:No
Enumeration Date:2009-10-27
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY814063-01367500000X
MARN2290194367500000X
TNRN0000159295367500000X
GARN173704367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered