Provider Demographics
NPI:1033729413
Name:MCCOY, CIERRA ROSE
Entity Type:Individual
Prefix:MS
First Name:CIERRA
Middle Name:ROSE
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 1:125 NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45410-1835
Mailing Address - Country:US
Mailing Address - Phone:937-694-3175
Mailing Address - Fax:
Practice Address - Street 1:3936 SADDLE RIDGE CIR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-4871
Practice Address - Country:US
Practice Address - Phone:937-938-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340916Medicaid