| Doctor Name: | MRS. THERESA MCCORMACK |
| NPI Number: | 1447611868 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PNP |
| License Number: | 0024165150 |
| Business Practice Address: | 2035 Waterside Rd Suite 105 Prince George, VA - 238751265 |
| Business Phone Number: | 8045200002 |
| Business Fax Number: | 8045202259 |
| Mailing Address: | 2035 Waterside Rd, Suite 105 PRINCE GEORGE |
| State: | VA |
| Postal Code: | 238751265 |
| Phone Number: | 8045200002 |
| Fax Number: | 8045202259 |
| NPI Enumeration Date: | 03/12/2016 |
| NPI Last Update Date: | 03/12/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0200X |
| License Number: | 0024165150 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | VA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Pediatrics |
| Taxonomy Definition: | |