Provider Demographics
NPI:1558816751
Name:MCCOY, TESSA E (NP)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:E
Last Name:MCCOY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:E
Other - Last Name:FUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014699363LF0000X
IN71008554A363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health