Provider Demographics
NPI:1558606897
Name:MAYCOCK, KHADJA (ARNP)
Entity type:Individual
Prefix:MRS
First Name:KHADJA
Middle Name:
Last Name:MAYCOCK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W COLONIAL DR
Mailing Address - Street 2:SUITE 187
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3400
Mailing Address - Country:US
Mailing Address - Phone:407-578-6610
Mailing Address - Fax:
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:SUITE 187
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3400
Practice Address - Country:US
Practice Address - Phone:407-578-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9203957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily