Provider Demographics
NPI:1477257061
Name:MCKOY, JODIANN CASSANDRA
Entity Type:Individual
Prefix:
First Name:JODIANN
Middle Name:CASSANDRA
Last Name:MCKOY
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 1:3640 PAULDING AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-1332
Mailing Address - Country:US
Mailing Address - Phone:347-607-5719
Mailing Address - Fax:
Practice Address - Street 1:3640 PAULDING AVE APT 3
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-1332
Practice Address - Country:US
Practice Address - Phone:347-607-5719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345496164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse