Provider Demographics
NPI:1518553585
Name:MCCOY, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CALLE MEDICO STE 1
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4761
Mailing Address - Country:US
Mailing Address - Phone:505-238-2814
Mailing Address - Fax:
Practice Address - Street 1:1273 S 2ND ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2234
Practice Address - Country:US
Practice Address - Phone:575-733-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker