Provider Demographics
NPI:1497928659
Name:MCCOY, LAVETTA A (RD, LD/N)
Entity Type:Individual
Prefix:
First Name:LAVETTA
Middle Name:A
Last Name:MCCOY
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150-9 TIMUQUANA RD.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-8959
Mailing Address - Country:US
Mailing Address - Phone:904-253-1510
Mailing Address - Fax:904-253-2517
Practice Address - Street 1:5150 TIMUQUANA RD.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-8959
Practice Address - Country:US
Practice Address - Phone:904-253-1510
Practice Address - Fax:904-253-2517
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4949133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered