Provider Demographics
NPI:1962570804
Name:MCCOY, TANJA (LPN)
Entity type:Individual
Prefix:MS
First Name:TANJA
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18648
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-0648
Mailing Address - Country:US
Mailing Address - Phone:216-215-0919
Mailing Address - Fax:216-583-9003
Practice Address - Street 1:1630 2 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641
Practice Address - Country:US
Practice Address - Phone:216-215-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN079519164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2239876Medicaid